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Foot health and amputation prevention for the long-term care resident

Older adults in nursing homes and long-term care facilities often have multiple health problems. With medical advances in the treatment of diabetes, aging Americans are living longer with the disease. In fact, as many as one in four nursing home residents has diabetes.

Foot health and amputation prevention programs for geriatric patients with diabetes are crucial to allowing the elderly to remain functional and independent. Patients with healthy feet can continue to walk and exercise. With proper foot care, falls and fractures can often be prevented.

As chief of podiatry and director of podiatric medical education at the Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and author of “Keep The Legs You Stand On,” it has been my personal and professional goal to reduce the rate of amputation for patients with diabetes.

That can be accomplished by identifying those who demonstrate high-level risk factors such as: decreased circulation, loss of protective sensation and pedal deformities. A thorough assessment and an individualized preventive care plan can prevent a triggering event of mechanical, thermal or chemical trauma that can lead to ulcers, infection, and ultimately, an amputation. A podiatrist can quickly identify those patients with foot deformities, vascular, neurological or pedal biomechanical problems and provide prompt and proper treatment, including prosthetic items, such as shoes, insoles braces and walking aids.

Geriatric and long-term care residents with diabetes have a greater risk for foot ulcers, infections and amputations due to diabetic neuropathy. Usually first observed as a tingling sensation, diabetic neuropathy often results in loss of sensation in the feet. This makes residents especially vulnerable to silent or painless trauma. For example, the resident may not feel a stone in their shoe or something dropping on their foot. They might be insensitive to an over-the-counter product that contains salicylic acid that destroys tissue painlessly. Or, they might not feel exposure to extreme heat, putting their feet close to a fire or heater and not being aware of a burn to the skin.

Once exposed to such trauma, residents with diabetes have several factors working against them to prevent or delay healing. They include: elevated blood glucose levels, immunopathy, peripheral arterial disease (PAD) or venous disease, smoking, and simply not practicing preventive foot behaviors, such as wearing shoes or visually inspecting their feet daily.

While all long-term care residents can benefit from preventive foot care, it could be life/limb saving for those who have lost protective sensation. The costs are minimal, especially when weighed against the potential expense for treatment. Diagnosis of loss of protective sensation with a monofilament testing device can easily be accomplished. Even if the resident is not able to provide self-care, nursing home staff can be educated in assisting with a daily routine whose benefits well outweigh the costs of treating an ulcer or infection in the hospital or an amputation, not to mention the lifetime rehabilitation costs.

A common problem

Amputations of lower extremities done for patients with diabetes are neither rare nor extreme.
In the United States, more than 83,000 are amputated yearly at a cost of more than $5 billion. Worldwide, 1 million lower extremity amputations are done for patients with diabetes. That’s one every 30 seconds.

What’s worse is that approximately 38% of patients who lose a leg will lose the other within three years. Nearly half of those who lose a leg won’t survive five years. However, there is hope. The U. S. Centers for Disease Control and Prevention estimates that up to 85% of these amputations can be prevented.

Long-term care facilities can focus on those statistically most vulnerable for lower extremity amputations. These patients fall into Category 3 in the evaluation scheme of the International Working Group for the Diabetic Foot.

First, they all have loss of protective sensation (LOPS) as defined by an inability to feel the 5.07/ 10 gm monofilament testing device on the bottom of their feet. They usually have a combination of autonomic, sensory or motor neuropathy that complicate healing of a foot wound. Many share a history of a previous amputation, foot ulcer, gangrene, claudication, rest pain, osteomyelitis, end-stage renal disease, previous vascular surgery on the legs, or a history of smoking.

Key evaluations that determine the patient’s risks for lower extremity amputation include:

* Vascular Evaluation of pulses in both feet.

* Neurological Evaluation with the 5.07/10 gm monofilament testing device to establish if the patient has or lacks protective sensation (LOPS).

* Foot Deformities Evaluation to classify osseous, soft tissue or nail deformities. Osseous deformities include any joint deformity of the foot such as hallux abducto valgus or bunion deformity, contracted digits that create hammer toe, claw toe, or mallet toe deformities and a tailor’s bunion-a deformity of the 5th metatarsal-phalangeal joint. Such bone deformities can create pressure points that rub against shoes or bedding, become inflamed, and lead to soft tissue breakdown or ulcers. Infected ulcers lead to osteomyelitis. The geriatric patient with diabetes will be challenged to heal these ulcers as they have neuropathy, PAD, and immunopathy. This combination of co-morbidities oftentimes delays or prevents healing, and because of infection and risk to the patient’s life, leads to amputation. Pressure against bony structures causes the body to protect itself by creating soft tissue deformities, called keratosis, or thickened skin lesions, called corns or calluses, that if left untreated can cause abscesses underneath them. Undetected and unfelt, these abscesses can lead to osteomyelitis and result in amputation.

* Nail deformities can also lead to amputation. A hypertrophic nail is vulnerable to pressure from the shoe pressing against it, causing an abscess underneath it. A thick, deformed and long nail can lacerate the adjacent digit. In both situations, if osteomyelitis results, amputation may be necessary.

To learn more about foot health, ulcers infection and lower extremity amputation prevention, visit my Web site at www.amputationprevention.com. The Web site has more information on amputation prevention and “Keep the Legs You Stand On,” the first educational book written for patients with diabetes and their caregivers on amputation prevention.


When Unna Boots Don’t Work

“Hi, I’m here for my Unna Boot,” said a smiling, slightly heavyset new patient of mine. He was a Vietnam Veteran who had sustained injuries to both legs in the war. I could sense his good nature and great attitude about his injury. “Doc, it was a Bouncing Betty that got me, and we have been taking care of my legs with Unna Boots.” A Bouncing Betty was a particularly vicious type of land mine that, once triggered, jumped up in the air about two to three feet and then sprayed shrapnel in all directions resulting in terrible injuries to the legs and lower torso of anyone close to it.

“Yes, I have been getting the Unna Boots applied to my legs for the past six years, and they work great, except that I need to come in every week to have them replaced,” he said. An Unna Boot, sometimes referred to as a “soft cast”, is a static type compression dressing that is wrapped around a leg to control swelling. It is typically made of a roll of gauze that has zinc oxide or calamine lotion in it.

Looking down at his legs he shared with me, “I do miss my swimming. You see, I can’t swim due to the ulcers on my legs and the yellow fluid that constantly drips from them.” I could see his problem; the dressings on his legs were soaked in that fluid. “We see and have successfully treated many types of wounds,” I reassured him, “so let’s take a look at your legs.”

Once the dressings on his legs were removed, I pursed my lips and shook my head when I saw the results of the Bouncing Betty trauma and Unna Boot treatment. His legs were swollen on either side of the Unna Boot dressing and looked like an outboard engine propeller had chewed them up. Huge areas of muscle were just gone, leaving deep invaginations of tissue. There were thick layers of dead skin on the surface of his legs and thick scars were seen where the shrapnel was surgically removed from his legs. There were at least a dozen superficial venous leg ulcers that gently and silently began to ooze yellow lymphatic fluid down his legs. The skin of the legs was macerated and infected due to the chronic moisture.

When I asked the patient about the condition of his skin, he replied, “This is pretty good for me.” I looked him straight in the eye and told him, “I am sorry; I don’t put Unna Boots on wounds like this. I prefer to heal them.

Confused and shocked he said, “Doc, no one else has ever told me my wounds could be healed. Are you saying you can heal my wounds and stop the dripping? Are you telling me I will be able to go swimming again?”

“Yes, I have healed similar wounds like yours. I believe we can heal your wounds AND you will be able to swim again.” He began to cry when he realized there was a chance to heal his ulcers and cure the infection. Then he abruptly stopped and said, “How do we do it?”

“The plan I have successfully used for many other patients with similar wounds involves us being partners. “I will do my part and you will be responsible for your part.” He agreed and asked, “When can we start?” I shared my plan with him and we started his healing that day.

  • First, we ordered a venous Doppler exam (a non-invasive and painless test) to be sure he did not have any blood clots in the veins in his legs. This was a necessary precaution in advance of using a NormaTec PCD to control and remove the chronic fluid overload in his legs that was the cause of the ulcers, yellow dripping fluid, and resultant infections.
  • Then, we started a process of removing the excess, thick, unhealthy tissue from his legs by manually scrubbing the skin with wound cleanser and a scrub brush, and applied white petroleum jelly to hydrate the skin. The ulcers were debrided to remove infected tissue from his wounds, thus reducing the bioburden on them and accelerating their healing. Tissue samples from the infected wounds were sent for Culture and Sensitivity and appropriate oral antibiotics, topical enzymatic debriding medications, and local wound care treatments were prescribed.
  • A NormaTec PCD was ordered and the patient used it religiously every day, starting at 15 minutes per treatment and reaching his goal of four hours every day. The plan of using the PCD to eliminate the fluid overload in the legs combined with meticulous wound care including periodic debridment, resulted in resolution of the infection, closing the ulcers. Moisturizing of the skin resulted in total closure of all ulcers and no further dripping of yellow lymphatic fluid.

It has been two years since the ulcers have healed. The patient continues to use the PCD four hours every day and stops by my office to chat. With his warm smile and happy aura, he shares stories about how delighted he is that his wounds are healed and he can finally swim again.

To view the entire article, please click here.


6 Key Steps to Preventing Diabetic Foot Ulcers and Amputations

Twenty first century technology is helping people with diabetes to heal foot ulcers. An Australian colleague, for example, is developing an application that reminds people with diabetes to control their blood sugars with prompts and instructions, and allows them to upload a picture of their wound for their podiatrist to evaluate.

This is just one small example of the time, energy and resources being devoted to dealing with diabetic foot ulcers AFTER they happen.

The CDC National Diabetes Fact Sheet reports that between 45 and 85% of lower extremity amputations can be prevented.1 The questions I have asked myself many times are why is this not happening? What are we waiting for? Why are so many people with diabetes continuing to lose legs? Shouldn’t more time, energy, and resources be devoted to preventing diabetic foot ulcers BEFORE they happen? I strongly believe that that the answer to my questions is prevention; an idea whose time has come for the diabetic foot.

Diabetic Foot Complications: Know the Facts
The fact is that one fourth of all people with diabetes will develop a foot ulcer2 and more than half of those foot ulcers will become infected, requiring hospitalization. Further, one in five will require an amputation.3

In the United States, there are approximately 100,000 non-traumatic lower extremity amputations performed for people with diabetes yearly — one every six minutes. Worldwide, there are more than 1 million non-traumatic lower extremity amputations performed for people with diabetes yearly, or one every 30 seconds.4,5

The cost of that care is astronomical. In the U.S., diabetes-related amputation costs are approximately $3 billion/year [$38,000/amputation procedure].6 In a 1995 study, the average cost of a minor amputation was $43,000; a major amputation cost $65,000.7 And worse, after a major amputation, half of those patients will have their other limb amputated within two years.8,9 The five-year mortality rate associated with diabetic lower extremity amputations is GREATER THAN all forms of cancer, except pancreatic and lung cancers combined.10

The Key to Preventing Diabetic Foot Ulcers and Amputations
If we can prevent a foot ulcer, then we can prevent subsequent infections, hospitalizations, and amputations. So, why aren’t foot ulcers being prevented?

I believe the answer is simple: People with diabetes are not currently getting an annual preventive foot health screening. Preventive foot health screenings that check circulation, identify foot deformities and incorporate a monofilament test can help people with diabetes keep their legs.

In a study released in 2010 by Thompson Reuters, the internationally recognized research and information firm, demonstrated that Medicare-eligible patients with a foot ulcer had a 18% lower risk of amputation, a 23% lower risk of a major amputation (constituting as a below-the-knee amputation or higher), and 9% lower risk of hospitalization when they had at least one visit to a podiatrist prior to the development of the ulcer.11

Here’s how it can be done:

Identify those patients who have diabetic sensory neuropathy by a monofilament test and stratify them into risk groups.
Identify foot deformities of the bones, soft tissues or nails.
Provide patient education on preventive foot health behaviors.
Address the identified pedal risk factors and provide appropriate care on a multidisciplinary basis to ameliorate the risk factors for developing a foot ulcer.
Offer ongoing foot care for local foot health problems.
Follow up with yearly preventive foot health screenings.
It has become part of our healthcare culture to endorse certain, limited preventive health screenings. Women have annual PAP smears and mammograms. Men have digital prostate exams. Dental hygiene is an accepted method to prevent tooth decay and identify oral health pathology. Many of us also have an annual eye exam. These screenings help identify lurking pathology and take proactive measures to prevent the consequences of the identified risks. So, it makes perfect sense to me that every person with diabetes should have a preventive foot health evaluation every year.

Medicare will pay for a retinal photograph to identify vascular pathology in the eye in order to prevent blindness. They will also cover the cost of lab testing for kidney function. So, two of the three most devastating complications of diabetes have covered screening exams for early identification of the risks of retinopathy and nephropathy. But, unfortunately, a yearly preventive foot health exam to identify diabetic sensory neuropathy is not a covered service.

I believe that if more time, energy, and resources were devoted to preventing foot ulcers by screening patients for risk factors for developing foot ulcers and creating awareness that amputations can be prevented, patients with diabetes would have better foot health, a better quality of life, and the overall cost of health care will be reduced.

To view the entire article, please click here.


If you are a person with diabetes, you have a good chance of having a bad foot problem.

CHECK OUT THIS GREAT NEW BOOK ON DIABETIC FOOT CARE!

Do you take your feet for granted, or appreciate how important they are to your way of life? Most of us don’t think about our feet until we have a problem — a pain, a sore or wound, or an injury.

Dr. Mark Hinkes has taken care of people’s feet for more than 30 years. Yet, it still frustrates him to see a

patient lose a toe, foot or leg due to a complication of diabetes.

Dr. Hinkes wrote Healthy Feet for People with Diabetes to help you and your caregiver prevent such a tragic alteration to your body and your life.


Patient Foot Care Guide for Prevention, Treatment and Self-Care

Every 30 seconds, someone loses a limb due to diabetes. Dr. Mark Hinkes, who has been a podiatrist for more than 30 years, has seen too many patients meet that fate, and decided to do something about it. Through his latest book, Healthy Feet for People with Diabetes (HealthyFeet, LLC; $29.99; August, 2012), he is focusing on prevention by providing a comprehensive guide to foot care with easy-to-follow steps for those most at risk of having foot problems.


Patient Foot Care Guide for Prevention, Treatment and Self-Care

Every 30 seconds, someone loses a limb due to diabetes. Dr. Mark Hinkes, who has been a podiatrist for more than 30 years, has seen too many patients meet that fate, and decided to do something about it. Through his latest book, Healthy Feet for People with Diabetes (HealthyFeet, LLC; $29.99; August, 2012), he is focusing on prevention by providing a comprehensive guide to foot care with easy-to-follow steps for those most at risk of having foot problems.

“People don’t need to endure foot ulcers, infections, and the debilitating loss of toes, feet, or legs; if they just took the time to learn and follow simple, practical steps to good foot health care, they could stop most foot problems before they get out of control,” Dr. Hinkes says.

Healthy Feet for People with Diabetes includes 20 concise, yet thorough, chapters offering users self-care techniques in an engaging blend of magazine and textbook formats, featuring large type, boxed lists, and images that make foot health issues easy to visually identify. Based on the latest scientific evidence, this 150-page book includes education on daily foot care and the management of common foot issues, to information specifically about the care team including podiatrists, health care providers and caregivers. An extensive resource section is also provided for both patient and clinician reference.

To make the book more user-friendly for patients, medical terms are simplified; Do’s and Don’ts are clearly identified; and there are “Top Tips” for everything from selecting socks and shoes, to skin care, to suggestions for caregivers.

For example, the 11-page Chapter on Shoes includes tips on the best (and worst) type of shoes for people with diabetes; guidelines on buying shoes; how to perform a daily shoe check; and descriptions of shoes designed for specific foot problems, with extra depth, insoles, custom molding, and other modifications.

The Table of Contents and first chapter of the book are available online at www.Dr-Mark.net. The book can be purchased by clicking here, with discounted rates for bulk quantities, as well as on Amazon.com, where it can also be downloaded as an e-book.

About Dr. Mark Hinkes

Dr. Hinkes has been Chief of Podiatry and Director of Podiatric Medical Education at the Veterans Affairs Medical Center/Tennessee Valley Healthcare System in Nashville, Tennessee. He was Chairman of the Preservation Amputation Care and Treatment (PACT) Program for a decade. He is certified by the American Board of Foot and Ankle Surgery​ and the American Professional Wound Care Association and is a Diplomat of the American College of Foot and Ankle Surgeons. He is a member of the American Podiatric Medical Association, the Federal Services Podiatric Medical Association and the American Diabetes Association.

Healthy Feet for People with Diabetes follows publication of his first book, Keep the Legs You Stand On.


FEATURED BOOK

Healthy Feet for People with Diabetes by Dr. Mark Hinkes

Every 30 seconds, someone loses a limb due to diabetes. Through his latest book,Healthy Feet for People with Diabetes, Dr. Mark Hinkes focuses on prevention by providing a comprehensive guide to foot care with easy-to-follow steps for those most at risk of having foot problems.

Healthy Feet for People with Diabetesincludes 20 concise yet thorough chapters offering users self-care techniques in an engaging blend of magazine and textbook formats. Based on the latest scientific evidence, this 150-page book includes education on daily foot care and the management of common foot issues, to information specifically about the care team including podiatrists, health care providers and caregivers. An extensive resource section is also provided for both patient and clinician reference.

» Click here for more information


PM News

Diabetics lose legs by not paying enough attention to their feet, said Dr. Mark Hinkes, chief of podiatry at the Veterans Affairs hospital in Nashville. Diabetics can lose sensation in their feet and be unaware of injury, allowing infection to spread to the bone and lead to an amputation. Yearly foot exams can diagnose if someone has lost sensation.

“Thirty-eight percent of the people who lose a leg are going to lose the other leg in three years,“ Hinkes said. “Fifty percent of the people who are diabetic who lose a leg won’t be here in five years.“

Source: Tom Wilemon, Ashland – City Times [11/17/13]


Dr. Mark Hinkes: When Unna Boots Don’t Work

Hi, I’m here for my Unna Boot,” said a smiling, slightly heavyset new patient of mine. He was a Vietnam Veteran who had sustained injuries to both legs in the war. I could sense his good nature and great attitude about his injury. “Doc, it was a Bouncing Betty that got me, and we have been taking care of my legs with Unna Boots… Click here to read more.


The Pedicurist’s Guide to the Diabetic Foot

Dr. Mark presents a webinar seminar on amputation prevention.

Link to Webinar


PM News

For more than 30 years, Dr. Mark Hinkes has seen his patients with diabetes suffer from pain, ulcers, and infections, just because they didn’t follow sound foot healthcare guidelines. His new book, Healthy Feet for People with Diabetes, focuses on prevention.

The comprehensive guide to foot care has easy-to-follow steps for those most at risk of having foot problems. “While it’s a great guide for patients, it has also been well received by podiatry office staff, foot care nurses, and even pedicurists,“ Dr. Hinkes says. Hinkes is Chief of Podiatry and Director of Podiatric Medical Education at the Veterans Affairs Medical Center/Tennessee Valley Healthcare System in Nashville, Tennessee.


Nail Event of the Smokies

nail-event-1nail-event-2nail-event-3nail-event-4noname (1)

Dr. Robert Spaulding with Dr. Hinkes

Dr. Robert Spaulding with Dr. Hinkes

“A Touch of Reality” radio Interview August, 2013

Dr. Mark speaking with Linda Evans, hostess of “A Touch of Reality”
Click here to listen to uncut interview

 


Dr.Mark visiting the National Theatre in Costa Rica

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