Short leg (SLW) and patellar tendon bearing walkers (PTBW) are orthotic appliances† which have been recently designed as alterna­ tive devices to traditional plaster cast immobili­ zation. The indications for use of lower leg walkers include severe ankle sprains, and ankle and foot fractures. Orthopedic walkers are con­ venient to use, lightweight, and removable to perform joint range of motion or inspect the ex­ tremity. Short leg walkers have been shown to be as effective as walking casts in healing stable ankle fractures, and patients treated with short leg walkers have shown significantly less edema, tenderness, and joint stiffness after six weeks of immobilization. 1 3 The authors feel that orthopedic walkers may also prove to be a beneficial alternative to traditional management of neuropathic fractures and plantar ulcer­ ations, which are commonly seen in diabetes mellitus and Hansen's disease.

BACKGROUND:A study was conducted to compare the accuracy, reliability, and essential features of nine commercially available handheld infrared thermometers used to manage the neuropathic foot. METHODS:The thermometers were compared using two temperature-control sources simulating physiologic conditions found in a foot-care clinic. With each control source independently set, temperature difference ranges of 0 degrees, 2 degrees, 4 degrees, and 6 degrees C were randomly sampled and analyzed for each thermometer by two testers. The order of testing was randomly assigned for testers and instruments. RESULTS:There were differences in mean temperature change among thermometers (P<.001) and between testers (P=.0247). Differences in mean temperature change among instruments (<0.5 degrees C), although small, could affect interpretation of skin temperature if temperature comparisons are made using two different instruments. The difference in temperature change between testers (0.06 degrees C) was not large enough to affect decisions in clinical practice. Instrument response time, distance-to-spot ratio, sensor diameter, display resolution, emissivity, and cost were compared. CONCLUSIONS:The low-cost, general-use infrared thermometers used in this study showed good accuracy, reliability, and performance and are appropriate for use in a foot-care clinic.

OBJECTIVE:To determine if the management of forefoot ulcerations through telemedicine is medically equivalent to ulcer care at a diabetes foot program.DESIGN:Nonrandomized comparison of forefoot ulcer healing rates.SETTING:The Louisiana State University Health Sciences Center Diabetes Foot Program, Baton Rouge, LA, and Lallie Kemp Medical Center, Independence, LA.PARTICIPANTS:Twenty consecutive patients with diabetes were treated for neuropathic forefoot ulcerations via telemedicine consultation and 120 consecutive patients with diabetes were treated face-to-face at a diabetes foot program.INTERVENTIONS:Management of forefoot ulcers by a certified wound care nurse trained in the use of a staged management approach algorithm and alternative off-loading methods, supported by real-time interactive telemedicine consultation.MAIN OUTCOME VARIABLES:Forefoot ulcer healing time in days, percentage of wounds healed in 12 weeks, and healing time ratio (adjusted for age, gender, ulcer duration, location, size, crossover, and grade).RESULTS:No differences were found between the telemedicine and diabetes foot program groups in the average forefoot ulcer healing time (43.2 + 29.3 vs. and 45.5 + 43.4 days, P =.828), the percent of forefoot ulcers healed in 12 weeks (75 % vs. 81%, P =.546) and the adjusted healing time ratio (1.40 vs 1.00, P =.104).CONCLUSION:These data appear to support the effectiveness of real-time interactive telemedicine consultation in the management of diabetes-related forefoot ulceration.

By the beginning of 1999, a Disease Management Initiative (DMI), consisting of targeted goals for the medical management of diabetes, had been established at all Louisiana State public hospitals. Concurrently, a regional Diabetes Foot Program (DFP) utilizing a staged management approach to foot problems was established in Baton Rouge. This study compares annual rates of hospitalization for diabetes-related foot problems and diabetes-related lower extremity amputations in diabetes patients treated for foot ulceration at the Louisiana public hospitals before and after implementation of DMI and the DFP. Mean diabetes foot-related hospitalization rates were lower in 1999 (1.96 per 100 person-years) compared to 1998 (2.61 per 100 person-years) (p < 0.001). Diabetes-related lower extremity amputation rates were also lower in 1999 (0.72 per 100 person-years) compared to 1998 (1.03 per 100 person-years) (p < 0.001). The reduction in the rate of foot-related hospitalizations was greater (p < 0.001) in patients after DMI and access to the DFP (-44%) compared to the patients after DMI without access to the DFP (-15%). There was no difference in the rate of lower extremity amputations between the patients with access to the DFP compared to the patients without access to the DFP. This study supports the effectiveness of a regional based DFP, providing a staged management approach to foot ulceration, in reducing foot-related hospitalizations, but not lower extremity amputations.

OBJECTIVE:To determine whether staged management of foot ulcers reduces health care costs and utilization.DESIGN:Nonrandomized retrospective study using data from 1998-1999 in the Louisiana public hospital system.SETTING:Louisiana public hospital system.PARTICIPANTS:Forty-five patients with diabetes foot ulcer who received staged management foot care and 169 patients with diabetes foot ulcer who received standard foot care.INTERVENTIONS:Staged management of foot ulcers consisting of devices to offload pressure; self-care education; and, after healing, custom-fabricated orthoses and footwear, and monitored progressive ambulation.MAIN OUTCOME MEASURES:One-year levels of the number of foot-related inpatient hospitalizations, number of amputation-related hospitalizations, total number of foot-related inpatient days, total charges for foot-related inpatient hospitalizations, all-cause outpatient visits, total charges for all-cause outpatient visits, and combined outpatient and foot-related inpatient charges.RESULTS:Over the 12-month study period, the staged management group had a lower foot-related hospitalization rate than did the comparison group (.09 admissions per person vs.50 admissions per person, P=.0002); lower foot-related inpatient days (.91d per person vs 3.97d per person, P=.0289); lower foot-related inpatient charges ($1321 per person vs $5411 per person, P=.0151); fewer amputation-related hospitalizations (.04 per person vs.19 per person, P=.0351); fewer emergency department visits (.60 visits per person vs 1.22 visits per person, P=.0043); lower emergency department charges ($104 per person vs $208 per person, P=.0057); and lower total charges ($4776 per person vs $9402 per person, P=.0141). The staged management group had a higher number of outpatient visits (24.91 per person vs 8.04 per person, P<.0001) and higher outpatient charges ($2169 per person vs $1471 per person, P<.0001).CONCLUSIONS:A staged management diabetes foot program significantly reduced emergency department and hospital utilization and charges in a statewide public hospital system.

OBJECTIVE To compare the healing rate of forefoot ulcers in patients with diabetes treated using a total contact cast with those treated using alternative off-loading methods. DESIGN Retrospective analysis of healing rates of forefoot ulcers. SETTING Louisiana State University Health Sciences Center Diabetes Foot Program, Baton Rouge, LA. PARTICIPANTS 120 consecutive patients with diabetes mellitus referred for treatment of new, nonsurgical forefoot ulceration. INTERVENTIONS Alternative off-loading methods (an accommodative dressing, a healing shoe, a walking splint) or a total contact cast. MAIN OUTCOME MEASURE Healing time of forefoot ulcers in days and percentage healed in 12 weeks. RESULTS 113 of 120 (94%) patients with forefoot ulcers healed in an average of 45.5 ± 43.4 days. Seven of 120 (5.8%) patients with ulcers either did not heal or were lost to follow-up. Stepwise lognormal regression showed ulcer grade (P <.001, R2 = 0.11) and width (P = .024, R2 = 0.05) were significantly related to healing time. After adding ulcer grade (1, 2, or 3) and width into the model, there was no difference between healing time in the accommodative dressing (P = .253), healing shoe (P = .815), and walking splint (P = .525) when compared with the total contact cast. Forefoot ulcers were closed within 12 weeks in at least 81% of cases irrespective of the off-loading method. CONCLUSION The healing rate of forefoot ulcerations in patients with diabetes using alternative off-loading methods or a total contact cast appeared to be comparable when the method was selected based on location of ulcer, patient age, and duration of ulceration.

This study evaluated the effect of levels of hardness of a commonly used orthosis material in reducing plantar pressure in patients at high-risk for foot ulcers. The mean peak pressure was measured, by using the Pedar System, on 19 patients with diabetes mellitus and a history of plantar foot ulceration. Patients walked in standard extra-depth shoes with no orthoses, standard extradepth shoes with 1/4-inch Poron® orthoses in seven different levels of hardness (14, 17, 22, 27, 32, 40, and 55 Shore “O” durometer), and their own nonstandardized footwear with molded orthoses. Mean peak walking pressures were lower in the standard shoes with the 22, 27, and 32 durometer Poron orthoses compared with those in the standard shoes with the 14, 17, and 55 durometer Poron orthoses. Walking pressures were lowest in the patients' nonstandardized footwear fitted with molded orthoses. Results support the use of medium-hardness Poron materials, which includes the current standard formulation (22 Shore “O” durometer), in orthosis fabrication in patients with diabetes at high risk for foot ulceration.

This dissertation reviews the pathomechanics of plantar ulceration in patients with diabetes mellitus, and studies the relationship between joint mobility, pressure and the location of ulceration at the first metatarsal head. Neuropathy, mechanical stress and vascular disease have been shown to be the primary causes of ulceration in patients with diabetes. Sensory neuropathy is considered the permissive cause of plantar ulceration. Plantar ulcerations do not occur without loss of sensation in the foot. Other factors including motor neuropathy, autonomic neuropathy, abnormal mechanical stress, foot deformity, joint limitation, and hyperkeratosis are considered important component causes in plantar ulceration. Autonomic neuropathy and vascular disease are trophic factors which cause tissues to be more susceptible to damage and ulceration, but are not direct causes. Motor neuropathy, foot deformity, joint limitation and hyperkeratosis are associated with high foot pressures. Individuals with high foot pressures and loss of protective sensation develop ulcerations from repeated injuries during walking. Plantar ulcerations commonly occur at the first metatarsal head. This study was conducted to determine if first ray joint limitation was related to ulceration at the first metatarsal head. Measurements of first ray mobility, pressure, and other physical measurements were made on 19 diabetic patients with a history of ulceration at the first metatarsal head, 20 diabetic patients with a history of ulceration at other locations of the forefoot, 19 matched diabetic, and 19 matched non-diabetic controls. Analysis of variance showed patients with a history of first metatarsal head ulceration had significantly lower first ray mobility and significantly higher pressure at the first metatarsal head compared to the other groups. Regression analysis showed a strong, negative, linear relationship between limited dorsiflexion of the first ray, and peak pressure and the pressure-time integral. Analysis of other physical measurements showed duration of diabetes was significantly higher, and sensation, range of motion at the hip, ankle and foot was significantly lower in patients with a history of ulceration compared to controls. The results demonstrate that the pathomechanical factors, limited joint mobility and high pressure, are significantly related to plantar ulceration and ulcer location in diabetes.

Physical Therapy Graduate Program University of Iowa Iowa City, Iowa Director of Physical Therapy Gillis W. Long Hansen's Disease Center Carville, Louisiana

Birke, James A. MS, PT; Novick, Andrew MA, PT; Hawkins, Elizabeth S. DPM, MPH; Patout, Charles Jr. MD Author Information

Novick, Andrew MA, PT; Birke, James A. MS, PT; Hoard, Alicia S. OTR; Brasseaux, Denise M. PT; Broussard, John B. PT; Hawkins, Elizabeth S. DPM, MPH Author Information