Katherine M. Raspovic

Self-Reported Quality of Life in Patients With Diabetes A Comparison of Patients With and Without Charcot Neuroarthropathy

Background: Previous reports using the Short Form-36 as a generic measure of quality of life have demonstrated reduced quality of life in patients with Charcot neuroarthropathy (CN). The aim of this study was to assess self-reported quality of life using the SF-36 and a region-specific assessment (the Foot and Ankle Ability Measure [FAAM]), hypothesizing that patients with diabetes and CN would have lower self-reported scores than patients with diabetes and no foot disease. Methods: Fifty patients with diabetes and CN were included in the study group. Fifty-six patients with diabetes and no pedal complaints comprised the control group. Quality of life was assessed with the SF-36 and the FAAM. Results: Patients with CN were more likely to have type 1 diabetes mellitus, were more likely to use insulin, had greater duration of diabetes, and were more likely to be neuropathic than patients in the control group. Patients with CN reported mean FAAM activities of daily living (ADL) scores that were 2 standard deviations below the control group and sports scores that were 1 standard deviation lower. There was no notable difference between the SF-36 mental component summary scores between the CN and control groups. SF-36 physical component summary scores in patients with CN were notably lower than scores in the control group. Conclusion: CN is associated with reduced quality of life as measured with the SF-36 and FAAM. To the best of our knowledge, this is the first study directly comparing self-reported outcome assessments in patients with both diabetes and CN and patients with diabetes without foot complaints. Level of Evidence: Level III, comparative series.

Self-Reported Quality of Life and Diabetic Foot Infections

Foot infections in patients with diabetes mellitus (DM) are serious complications that can result in hospitalization, the need for amputation, and premature mortality. To the best of our knowledge, no published studies have specifically investigated the effect of diabetic foot infection (DFI) on patient quality of life. The aim of the present study was to compare the self-reported assessments of quality of life in patients hospitalized with DFIs with those from a group of patients without foot infections. We evaluated a study group of 47 patients who had been hospitalized with DFIs and a control group of 47 patients with DM who did not have any complaints referable to their foot or ankle. The self-reported outcomes were assessed using the Medical Outcomes Study short form 36-item health survey (SF-36) and the Foot and Ankle Ability Measurement. Patients hospitalized with DFIs had significantly reduced self-reported SF-36 scores in all 8 subscales compared with the cohort of patients with DM without foot complaints. The SF-36 physical component and mental component scores were significantly reduced in patients with DFIs, indicating a negative effect on overall health. Self-reported lower extremity function was also negatively affected with significantly lower Foot and Ankle Measurement activity of daily living and sports scores for patients with DFI. The present study has demonstrated the profoundly negative affect that moderate and severe DFIs have on self-reported quality of life, affecting both physical and mental well-being and lower extremity function.

Radiographic analysis of diabetic midfoot charcot neuroarthropathy with and without midfoot ulceration.

Background: The aim of this study was to evaluate weight-bearing radiographs in patients with and without foot ulcers diagnosed with midfoot Charcot neuroarthropathy (CN) secondary to diabetes mellitus. Methods: One hundred fourteen patients with midfoot CN (50 with foot ulcers and 64 without ulcers) were identified and included in this study. Nine radiographic measurements were made (7 in the sagittal plane and 2 in the transverse plane). Results: CN patients with foot ulcers had significantly greater deformity when assessing the lateral-talar first metatarsal angle, calcaneal pitch, cuboid height, medial column height, calcaneal-fifth metatarsal angle, talar declination, and lateral tibiotalar angle. Two measurements in the transverse plane (hindfoot-forefoot angle and AP talar first metatarsal angle) were not significantly different between the 2 groups. Of patients with foot ulcers, 24% had a lateral talar first metatarsal angle of less than −27 degrees and 80% had a negative cuboid height. Conclusion: Sagittal plane deformities were more likely to be associated with foot ulceration in patients with CN than transverse plane deformities. Lateral column involvement was associated with a worse prognosis than medial column involvement, thus we believe progressive deformity of the lateral column should be monitored closely to prevent foot ulceration. Lateral column involvement could be identified by a decrease in the cuboid height, decreased calcaneal pitch, and decreased lateral calcaneal fifth metatarsal angle. This study can assist physicians in stratifying the risk for both ulceration and need for surgery in patients with CN based on reproducible radiographic measurements. Level of Evidence: Level III, comparative series.

SIRS Is Valid in Discriminating Between Severe and Moderate Diabetic Foot Infections

OBJECTIVE This retrospective, single-center study was designed to distinguish severe diabetic foot infection (DFI) from moderate DFI based on the presence or absence of systemic inflammatory response syndrome (SIRS). RESEARCH DESIGN AND METHODS The database of a single academic foot and ankle program was reviewed and 119 patients were identified. Severe DFI was defined as local infection associated with manifestation of two or more objective findings of systemic toxicity using SIRS criteria. RESULTS Patients with severe DFI experienced a 2.55-fold higher risk of any amputation (95% CI 1.21–5.36) and a 7.12-fold higher risk of major amputation (1.83–41.05) than patients with moderate DFI. The risk of minor amputations was not significantly different between the two groups (odds ratio 1.02 [95% CI 0.51–2.28]). The odds of having a severe DFI was 7.82 times higher in patients who presented with gangrene (2.03–44.81) and five times higher in patients who reported symptoms of anorexia, chills, nausea, or vomiting (2.22–11.25). The mean hospital length of stay for patients with severe DFI was ∼4 days longer than for patients with moderate DFI, and this difference was statistically significant. CONCLUSIONS SIRS is valid in distinguishing severe from moderate DFI in hospitalized patients. Patients with severe DFI, as by manifesting two or more signs of systemic inflammation or toxicity, had higher rates of major amputation and longer hospital stays and required more surgery and more subsequent admissions than patients who did not manifest SIRS.

Noninvasive Arterial Testing in Patients With Diabetes A Guide for Foot and Ankle Surgeons

Background: This study was designed to compare the findings of noninvasive arterial testing in patients with and without diabetic foot pathology. Methods: The ABI (ankle brachial index), TBI (toe brachial index), and great toe pressures were measured in 207 patients. PAD (peripheral artery disease) was defined as an ABI < 0.91 on either extremity or a TBI < 0.7. Results: PAD was identified in 103 of the 207 patients (49.8%), 80 patients with diabetic foot pathology and 23 patients with nondiabetic foot pathology. Although patients with diabetic foot pathology were 1.4 times more likely to have PAD compared to patients without diabetic pathology, this increased risk was not statistically significant (OR 1.41 [95% CI 0.75-2.64], P = .28). Patients with PAD and diabetic foot pathology were 4.9 times more likely to have ischemia (toe pressure < 60 mm Hg) than patients with PAD and nondiabetic foot pathology (OR 4.93 [95% CI 1.35-17.94], P < .05). Patients on dialysis had a 7.3 times increased likelihood of having PAD compared to patients not on dialysis (OR 7.3 [95% CI 1.6-33.6], P < .01). Patients with absent pedal pulses were 4.9 more likely to have PAD than patients with normal pulses (OR 4.9 [95% CI 2.6-9.4], P < .0001). PAD was identified in 97 of 188 patients (51.6%) with peripheral neuropathy compared to 6 of 19 patients (31.5%) without peripheral neuropathy (OR 2.31 [95% CI 0.84-6.33], P = .10). Conclusions: Combining the ABI with TBI improved the ability to diagnose PAD in diabetic patients because the ABI has high specificity (low false positives) and the TBI has high sensitivity (low false negatives). The TBI was more reliable in patients with noncompressible arteries, medial artery calcinosis and/or neuropathy. Due to the relative incompressibility of calcified distal arteries in patients with DM, the ABI may be within normal limits in patients with PAD. This false negative result may lead surgeons to assume that normal perfusion is present. Level of Evidence: Level III, comparative study.

Midfoot Charcot Neuroarthropathy in Patients With Diabetes The Impact of Foot Ulceration on Self-Reported Quality of Life

Introduction. Charcot neuroarthropathy (CN) and diabetic foot ulceration (DFU) are serious complications of diabetes mellitus (DM) that can result in infection, hospitalization, amputation, and have been shown to negatively affect quality of life (QOL). To the best of our knowledge, there are no studies in the literature that have specifically compared QOL in patients with diabetic CN without DFU to a group of patients with diabetic CN and concurrent DFU. The aim of this study was to compare self-reported assessments of QOL in patients with CN to a group of patients with CN and concomitant midfoot ulceration. Materials and Methods. We compared a group of 35 diabetic patients with midfoot CN and no ulcer to a group of 22 diabetic patients with midfoot CN and concurrent DFU. Self-reported outcome was assessed using the Medical Outcome Study Short Form 36 (SF-36) health survey and Foot and Ankle Ability Measure (FAAM). Results. No significant differences were found when comparing the 2 groups utilizing the SF-36 and FAAM with the exception that CN patients without foot ulcers had lower mean scores on the Bodily Pain Subscale. Both groups demonstrated negative impact on physical QOL and lower extremity function to a greater degree than mental QOL. Conclusion. The presence of ulceration does not appear to significantly impact QOL in patients with CN when compared to patients with CN without ulceration. Levels of Evidence: Prognostic, Level III: Case control

Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes

Charcot neuroarthropathy (CN) of the ankle and hindfoot (Sanders/Frykberg Type IV) is challenging to treat surgically or nonsurgically. The deformities associated with ankle/hindfoot CN are often multiplanar, resulting in sagittal, frontal and rotational malalignment. In addition, shortening of the limb often occurs from collapse of the distal tibia, talus and calcaneus. These deformities also result in significant alterations in the biomechanics of the foot. For example, a varus ankle/hindfoot results in increased lateral column plantar pressure of the foot, predisposing the patient to lateral foot ulceration. Collapse of the talus, secondary to avascular necrosis or neuropathic fracture, further accentuates these deformities and contributes to a limb‐length inequality.

Patients With Diabetic Foot Disease Fear Major Lower-Extremity Amputation More Than Death

Background. The aim of this study was to identify the most-feared complications of diabetes mellitus (DM), comparing those with diabetic foot pathology with those without diabetic foot pathology. Methods. We determined the frequency of patients ranking major lower-extremity amputation (LEA) as their greatest fear in comparison to blindness, death, diabetic foot infection (DFI), or end-stage renal disease (ESRD) requiring dialysis. We further categorized the study group patients (N = 207) by their pathology such as diabetic foot ulcer (DFU), Charcot neuroarthropathy, foot infection, or acute neuropathic fractures and dislocations. The control group (N = 254) was comprised of patients with diabetes who presented with common non–diabetes-related foot pathology. Results. A total of 461 patients were enrolled in this study and included 254 patients without diabetic foot complications and 207 patients with diabetic foot problems. When comparing patients with and without diabetic disease, no significant differences were observed with regard to their fear of blindness, DFI, or ESRD requiring dialysis. Patients with diabetic foot disease (61 of 207, 31.9%) were 136% more likely (odds ratio [OR] = 2.36; 95% CI = 1.51-3.70; P = .002] to rank major LEA as their greatest fear when compared with diabetic patients without foot disease (42 of 254, 16.5%) and were 49% less likely (OR = 0.51; 95% CI = 0.34-0.79; P = .002) to rank death as their greatest fear compared with patients without diabetic foot disease. Conclusion. Patients with diabetic foot pathology fear major LEA more than death, foot infection, or ESRD. Variables that were associated with ranking LEA as the greatest fear were the presence of a diabetic-related foot complication, duration of DM ≥10 years, insulin use, and the presence of peripheral neuropathy. Levels of Evidence: Level II: Prospective, Case controlled study

Comparison of Transtibial Amputations in Diabetic Patients With and Without End-Stage Renal Disease.

Background: The primary purpose of this retrospective study was to report on a consecutive series of 102 patients with diabetes mellitus (DM) who underwent transtibial amputation (TTA) for chronic infections and nonreconstructable lower extremity deformities. A secondary aim was to compare the outcomes of TTA patients with end-stage renal disease on dialysis (ESRD) to patients without ESRD, and to identify risk factors for mortality after TTA. Methods: This cohort involved a consecutive series of patients who were treated by a single surgeon. The TTA patients were divided into 2 groups for analysis. The study group included those patients with ESRD who underwent TTA, and the control group included those patients who did not have ESRD. Results: At the time of final follow-up, 64 of 102 patients were ambulatory with a prosthesis. There was a significant improvement in ambulatory status after amputation (preoperatively 45.1%, postoperatively 62.7%, P = .02). Wound healing complications (infection and/or dehiscence) occurred in 31 of 102 patients and led to a transfemoral amputation in 4 patients. After TTA patients with ESRD were significantly more likely to die (52.4% vs. 23.5%, p <0.05) and significantly less like to ambulate (42.9% vs. 67.9%, p <0.05) than patients without ESRD. Contralateral foot problems after the TTA occurred in 33 of 97 patients and resulted in 10 patients undergoing a contralateral transtibial amputation. Excluding patients with bilateral amputations (5 prior to and 10 after the index amputation), 64 of 87 patients with successful unilateral transtibial amputations were able to ambulate with a prosthesis. Thirty of 102 patients (29.4%) died during the follow-up period, and 6 of these deaths occurred during the perioperative period (within 30 days of surgery). There were no significant differences between the 2 groups with regard to the use of staged TTA, need for transfemoral amputation, or wound healing problems at the amputation site. Patients who were unable to walk postoperatively had a calculated 5-year survival rate of 30.1%, whereas those who were ambulatory had a 5-year survival rate of 68.8%. Cox proportional hazards model demonstrated a 62% reduced risk of mortality in patients who were able to ambulate after LEA compared with those patients who were not able to ambulate. Conclusion: TTA in patients with diabetes was associated with substantial morbidity and mortality. Risk factors that were significantly associated with an increased rate of mortality were the presence of ESRD, age ≥56 years, and inability to ambulate postoperatively. Level of Evidence: Level III, retrospective case controlled study.

End-Stage Renal Disease Negatively Affects Physical Quality of Life in Patients With Diabetic Foot Complications:

The aim of this study was to evaluate the impact of end-stage renal disease (ESRD) on health-related quality of life (QOL) in patients with diabetic foot disease. We compared a group of 30 diabetic patients with ESRD requiring dialysis to a group of 60 diabetic patients without ESRD. Both groups consisted of patients with active diabetic foot disease (ulcer, Charcot, infection) and were matched with regard to age and gender. Self-reported QOL was assessed using the Short Form-36 (SF-36) physical and mental component summary (PCS and MCS) scores and the region-specific Foot and Ankle Ability Measure (FAAM). Diabetic foot patients with ESRD requiring dialysis were found to have significantly higher creatinine levels, lower hemoglobin levels, lower albumin levels, higher rates of peripheral arterial disease, and lower rates of Charcot neuroarthropathy than patients without ESRD. The median PCS was significantly lower in the ESRD group; however, no significant difference was found when comparing the median MCS and FAAM. Patients who ultimately died had a tendency to report lower PCS scores at baseline compared with those patients who did not die (P = .07). Patients who ultimately required major amputation also reported lower PCS scores at baseline. ESRD negatively affects physical QOL to a greater degree than mental QOL in patients with diabetic foot disease. The SF-36 may not be sensitive enough to capture impaired mental QOL because both groups had relatively high MCS scores. Low physical QOL may be associated with mortality and the eventual need for major amputation.