April 2010

In the moment: Diabetes

By Jordana Bieze Foster

A push for collaboration

Teamwork keys amputation prevention

The photo shows a hospital scene that under different circumstances might be comical. A patient with a diabetic foot problem lies in a bed, surrounded by practitioners. But none of the practitioners are communicating with each other, and all but one have their backs to the patient.

Karel Bakker, MD, a retired internist and endocrinologist from Spaarne Hospital in Heemstede, the Netherlands, first showed this photo at a lecture eight years ago to illustrate the lack of teamwork that is too often characteristic of the foot care received by patients with diabetes.

“Unfortunately, this is in many cases still true today,” Bakker said in March at the annual meeting of the Diabetic Foot Global Conference in Los Angeles.

Once again, Bakker showed the photo. And again he reiterated the need for teamwork

“There is strong evidence that a multidisciplinary foot care team can decrease amputation rates,” Bakker said.

That theme was repeated by multiple speakers throughout the conference, as diabetic foot care experts from around the world described their ongoing efforts to coordinate patient care, the successes, the frustrations, and the work that still needs to be done.

“I would like to see a shift from procedure based medicine to disease based medicine, and I think that’s what we’re talking about with this type of multidisciplinary care,” said George Andros, MD, medical director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles, and a co-chairman of the conference.

Earlier in the week, conference attendees were invited to help celebrate the opening of Valley Presbyterian’s new multidisciplinary foot care center. Its mission is to follow the example set by other such centers around the world that have been associated with precipitous drops in amputation rates.

One of the best known is the Ipswich Diabetic Foot Unit at Ipswich Hospital in the United Kingdom. There, incidence of total amputations in patients with diabetes decreased by 70% over an 11-year period, and incidence of major amputations decreased by 82%, as reported in the January 2008 issue of Diabetes Care.

Gerry Rayman, MD, head of service at the center, took the podium in Los Angeles to describe the Ipswich system, which includes primary care from chiropodists, practice nurses, distric nurses and general practitioners, and secondary care from diabetologists, podiatrists, orthotists, vascular surgeons, and infectious disease specialists.

The center also utilizes a simplified referral system based on a patient’s risk factors. Those at high risk are referred to the foot care team, while those at moderate risk are referred to the foot protection team.

“If we want to engage everyone, we have to keep it simple,” Rayman said.

One of the primary advantages of having multiple specialties working under one roof is the ability to streamline referrals.

“If you have to refer, you’re losing time. There’s a problem with creep,” said David Armstrong, DPM, PhD, professor of surgery and director of the Southern Arizona Limb Salvage Alliance at the University of Arizona in Tucson, and a co-chairman of the conference.

Communication is key to team-oriented care. And it’s not always easy, according to John S. Steinberg, DPM, co-director of the multidisciplinary Center for Wound Healing at Georgetown University Hospital in Washington, D.C.

“Communication is our strong point and our weak point,” Steinberg said. “You do a week’s worth of work in a single visit when you’re all there at the same time. But the logistics of making that happen are a challenge.”

But the results from Rayman and others speak for themselves, as Andrew J.M. Boulton, MD, DSc, professor of medicine at the University of Manchester (U.K.) and the University of Miami, noted in his closing remarks.

“The most important thing,” Boulton said, “is that we work together as a team.”

Large, stubborn foot wounds respond to treatment with platelet rich plasma

Platelet rich plasma may be a hot topic in sports medicine, but it also can be effective for achieving healing in diabetic foot ulcers that are resistant to other forms of treatment, according to research presented in March at the Diabetic Foot Global Conference.

Investigators from the Carl T. Hayden Veterans Administration Hospital in Phoenix, AZ, used autologous platelet-rich plasma gel on 14 recalcitrant wounds in 10 patients with diabetes. The wounds had remained unhealed for a mean of 45 weeks despite comprehensive wound management. The wounds were large, with a mean area of 10.4 cm2 and a mean volume of 23.5 cm3 at baseline.

Treatment duration lasted a mean of 3.9 weeks, during which time a mean of 3.6 doses were applied. Twelve of the wounds (85.7%) responded positively, averaging a 75.4% decrease in volume and a 67.2% decrease in area. In particular, wounds with undermining experienced mean volume reductions of 77.3% in 4.1 weeks, while wounds with sinus tracks and tunneling shrank by a mean of 69.1% in just 2.5 weeks.

Surgical group heals nearly all forefoot, midfoot ulcers with tendon lengthening

Tendon lengthening outcomes from a single orthopedic practice in New Orleans reflect nearly perfect rates of diabetic ulcer healing and low rates of recurrence, according to a presentation in March at the annual meeting of the American Academy of Orthopaedic Surgeons.

J. Monroe Laborde, MD, a surgeon with Orthopaedic Associates of New Orleans, presented data on tendon lengthening for forefoot and midfoot plantar ulcers performed between 1995 and 2006.

Overall, 98% of ulcers healed and 16% recurred. Forty six toe ulcers all healed after percutaneous toe flexor tenotomy, with three recurrences. All but one of 44 metatarsal ulcers healed following gastrocnemius-soleus recession plus lengthening of the peroneus longus tendon, with seven recurrences. Nine of 10 midfoot ulcers healed with gastrocnemius-soleus recession plus a custom molded insert, with no recurrences.

Asked if his results meant that he was now seeing patients referred for tendon lengthening sooner than in the past, Laborde answered, “Not as often as I would like. I think there’s a lot of resistance from (other specialties) to this treatment because it decreases their income.”

Offloading device discussion explores underutilization of total contact casting

Of all the interventions that can reduce plantar pressures in patients with diabetes, only the total contact cast and similar non-removable devices can boast high-level evidence of actual ulcer prevention. And yet TCC utilization by practitioners remains poor.

This conundrum is not a new one, but it is once again a topic of discussion following the February e-publication of a new set of telling data from the University of Texas Health Science Center. And in March, the same issue served as the foundation for the offloading workshop led by diabetic foot biomechanics expert Peter Cavanagh, PhD, DSc, at the Diabetic Foot Global Conference in Los Angeles.

“There is a huge discrepancy between what the evidence shows to be the case and what we are actually doing,” said Cavanagh, who is now professor and endowed chair in women’s sports medicine and lifetime fitness at the University of Washington in Seattle but remains active in diabetic foot research.

The Texas study, e-published on Feb. 16 by Wound Repair & Regeneration, is a case in point. Its authors found that only 6% of patients with diabetic foot ulcers treated at hospital based wound centers received total contact casting, despite the fact that the average cost of treatment with TCC was half that of treatment with other modalities.

The time consuming nature of total contact casting might be one explanation, the authors suggested; lack of familiarity with evidence-based clinical practice guidelines might be another. A third underlying factor is likely compensation; ironically, expensive therapies like dermal substitutes are reimbursed more generously than TCC.

“The economic model is driving products that are more expensive over treatments that are more effective,” Cavanagh said.

The bottom line, he said, is that the existing evidence only supports offloading devices that cannot be removed, which in addition to TCC includes ankle foot orthoses that can be locked in place. Compliance, of course, is the key issue.

“The literature tells us that if a patient can remove a device, they will remove a device,” he said. “The guidelines can only be made from the evidence. So there are only a couple of recommendations that can be made.”

As effective as non-removable devices are, Cavanagh cautioned, practitioners should still guard against ulcer formation – on the contralateral foot.

“Many patients take the cast as a license to increase their activity level,” he said, “which may be risky for the other foot.”

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