A little bit of information can be dangerous. Not all what comes out of the mouths of "specialists" should be believed.

DISASTERS AVERTED — Near Miss Case Studies

Preventing Lower Leg Amputation Editor's Note Often times when we see a diabetes patient, the first thing we look for are problems with the feet. When I meet a new patient, I always ask whether they have seen a podiatrist. These physicians specialize in problems from the tips of the toes to the tops of the ankles, and no one is more fit to diagnose and treat foot problems. To decrease pain, some podiatrists will offer to file down calluses and this brings relief to many patients. However, this practice may not be the best for everyone according to the Director of a Peripheral Vascular Disease Clinic in New York and this week's Disaster Averted author, who has information onwhy indiscriminate callus care can lead to amputations and what can be done to avoid them. Our Homerun Slides finish up with the third part of Wellness Initiatives in the Workplace, and ourClinical Text focuses again on Diabetic Ketoacidosis in Childhood and Adolescence. Our Mastery In Minutes video with Brian Wansink will give you practical tips to pass on to patients on which diet is best for them. Your partner in diabetes care,  Dave Joffe  Editor-in-chief

Preventing Lower Leg Amputation

I have served for 29 years in the Peripheral Vascular Disease Clinic of a large metropolitan hospital. We see many diabetic patients who have already lost all or part of one leg and want us to care for the remaining extremity. When I interview these patients, I always ask for the cause of the initial amputation. In every case, it has been an attempt to grind down or remove a callus, usually by a podiatrist but sometimes by the patient or a family member. I've also seen instances in my private practice of foot infections stemming from this kind of intervention….

In one striking case, I saw a patient in my office on a Friday after­noon. Both his feet were without wounds. Unbeknownst to me, he made a routine visit to his podiatrist that evening. On Monday morning, I received a phone call from his podiatrist asking what antibiotic I wanted him to prescribe. I advised him to send the patient to my office.

Immediately, I asked the patient what had occurred. He stated that the podiatrist had ground down a callus on his great toe with a pumice stone. I removed 5 ml. of pus from his swollen, inflamed toe.

Lesson Learned:

In spite of the frequency of this scenario, the American Diabetes Association still recommends "Callus can be debrided with a scalpel by a foot care specialist or other health care professional."

Patient-oriented publications distributed by this professional organization actually advertise motorized grinding stones for use by patients on their own calluses!

Calluses occur naturally over pressure or shear sites to protect the underlying skin from injury. The appropriate treatment of calluses is to eliminate the pressure or shear. This is readily accomplished by stretching or replacing offending shoes or by providing orthotic shoe inserts to redistribute load. If this treatment were to become routine, tens or even hundreds of thousands of amputations could be prevented annually in the USA alone.

Richard K. Bernstein, M.D., F.A.C.E., F.A.C.N., C.W.S., FCCWS

References:

1. Holman N. Young RJ, Jeffcoate WJ (2012) Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia 10.1007/s00125-012-2468-6
2. N.C. Shaper, J. Apelquist and K. Baker, Reducing Lower Leg Amputa­tion in Diabetes: a challenge for patients, healthcare providers and the healthcare system, Diabetologia, 10. 1007/500125-012-2588-7, 24 May, 2012.
3. American Diabetes Association, Standards of Medical Care In Diabetes – 2012, Diabetes Care 35:Supp. 1, p. 538, Jan. 2012

From the Peripheral Vascular Disease Clinic, Albert Einstein College of Medicine, Jacobi Medical Center, Bronx, New York, and the New York Diabetes Center, Mamaroneck, New York. DOI: 10.2337/dc12-2085
Copyright © 2013 by the American Diabetes Association.