Postoperative Opioid-Prescribing Practice in Limb Preservation Surgery.

BACKGROUND: Limb preservation surgery affects more than 100,000 Americans annually. Current postoperative pain management prescribing practices of podiatric physicians in the United States are understudied. We examined prescribing practices for limb preservation surgery to identify prescriber characteristics' that may be associated with postoperative opioid-prescribing practices. METHODS: We administered an anonymous online questionnaire consisting of five patient scenarios with limb preservation surgery commonly performed by podiatric physicians. Respondents provided information about their prescription choice for each surgery. Basic provider demographics were collected. We developed linear regression models to identify the strength and direction of association between prescriber characteristics and quantity of postoperative opioid "pills" (dosage units) prescribed at surgery. Logistic regression models were used to identify the odds of prescribing opioids for each scenario. RESULTS: One hundred fifteen podiatric physicians completed the survey. Podiatric physicians reported using regional nerve blocks 70% to 88% of the time and prescribing opioids 43% to 67% of the time across all scenarios. Opioids were more commonly prescribed than nonsteroidal anti-inflammatory drugs and anticonvulsants. Practicing in the Northeast United States was a significant variable in linear regression (P = .009, a decrease of 9-10 dosage units) and logistic regression (odds ratio, 0.23; 95% confidence interval, 0.07-0.68; P = .008) models for the transmetatarsal amputation scenario. CONCLUSIONS: Prescribing practice variation exists in limb preservation surgery by region. Podiatric physicians reported using preoperative regional nerve blocks more than prescribing postoperative opioids for limb preservation surgeries. Through excess opioid prescribing, the diabetes pandemic has likely contributed to the US opioid epidemic. Podiatric physicians stand at the intersection of these two public health crises and are equipped to reduce their impact via preventive foot care and prescribing nonopioid analgesics when warranted.

Effectiveness of a Continuous Remote Temperature Monitoring Program to Reduce Foot Ulcers and Amputations: Multicenter Postmarket Registry Study.

BACKGROUND: Neuropathic foot ulcers are the leading cause of nontraumatic foot amputations, particularly among patients with diabetes. Traditional methods of monitoring and managing these patients are periodic in-person clinic visits, which are passive and may be insufficient for preventing neuropathic foot ulcers and amputations. Continuous remote temperature monitoring has the potential to capture the critical period before the foot ulcers develop and to improve outcomes by providing real-time data and early interventions. For the first time, the effectiveness of such a strategy to prevent neuropathic foot ulcers and related complications among high-risk patients in a real-world commercial setting is reported. OBJECTIVE: This study aims to evaluate the effectiveness of a real-world continuous remote temperature monitoring program in preventing neuropathic foot ulcers and amputations in patients with diabetes. METHODS: In this retrospective analysis of a real-world continuous remote temperature monitoring program, 115 high-risk patients identified by clinical providers from 15 geographically diverse private podiatry offices were analyzed. Patients received continuous remote monitoring socks as part of the program. The enrollment was based on medical necessity as decided by their managing physician. We evaluated data from up to 2 years before enrollment and up to 3 years during the program. The primary outcome was the rate of wound development. Secondary outcomes included amputation rate, the severity of the foot ulcers, and the number of visits to an outpatient podiatry clinic after enrolling in the program. RESULTS: We observed significantly lower rates of foot ulceration (relative risk reduction [RRR] 0.68; 95% CI 0.52-0.79; number needed to treat [NNT] 5.0; P<.001), less moderate to severe ulcers (RRR 0.86; 95% CI 0.70-0.93; NNT 16.2; P<.001), less amputations (RRR 0.83; 95% CI 0.39-0.95; NNT 41.7; P=.006), and less hospitalizations (RRR 0.63; 95% CI 0.33-0.80; NNT 5.7; P<.002). We found a decrease in outpatient podiatry office visits during the program (RRR 0.31; 95% CI 0.24-0.37; NNT 0.46; P<.001). CONCLUSIONS: Our findings suggested that a real-world continuous remote temperature monitoring program was an effective strategy to prevent foot ulcer development and nontraumatic foot amputation among high-risk patients.

Postprocedural Opioid-Prescribing Practice in Nail Surgery.

BACKGROUND: Ingrown toenails are a common condition requiring outpatient procedures in podiatric medical clinics. To prevent recurrence, chemical matrixectomy is often recommended. Postprocedural pain management is largely based on preferences rather than on a formal guideline. This study aims to explore the postprocedural prescribing behavior among practicing podiatric physicians to foster future guideline and policy development. METHODS: We administered an open, voluntary, anonymous questionnaire via an online survey platform that included a common nail procedure scenario (chemical matrixectomy) and a prescribed demographics section. Podiatric physicians were asked what they would prescribe to manage postprocedural pain. Opioid and nonopioid options were provided. We developed two multiple logistic regression models to identify associations between prescriber characteristics and prescribing opioids after "standard" chemical matrixectomy. RESULTS: Of the 860 podiatrists who completed the survey, 8.7% opted to prescribe an opioid. Hydrocodone was most commonly chosen. A median of 18 opioid pills were prescribed. No prescriber characteristics were associated with prescribing opioids after chemical matrixectomy scenario. There is a large discrepancy and knowledge gap in the literature on the optimal postprocedural pain management for outpatient procedures, including procedures in specialties such as dentistry and dermatology. The median number of opioids prescribed by podiatrists is higher than that by dentists for management of third molar extraction. In contrast, opioid-prescribing behavior among the 8.7% of respondents is similar to dermatologic management of postprocedural pain in Mohs surgery. CONCLUSIONS: Podiatric physicians cannot assume that their prescribing of opioids does not affect the opioid abuse problem in the United States. The presented study serves to be an initiation for procedure-specific opioid prescription benchmarking to foster future guideline and policy development. After nail procedures, opioids should not be routinely prescribed.

Medicaid Coverage for Routine Foot Care.

BACKGROUND: Despite national and international guidelines supporting podiatric services as a means of prevention for lower-extremity complications, especially in at-risk individuals, current coverage for these services under the US Medicaid program is not universal. The vast differences between state Medicaid programs regarding reimbursable foot care services is confusing and potentially serves as a barrier for the most vulnerable populations to receive preventative services. This article provides a brief discussion of "routine" podiatric services from a clinical perspective and provides a review of state Medicaid programs including optional services (eg, podiatric coverage). METHODS: Using data from a national survey of state Medicaid programs, we present and discuss common Medicaid coverage schemes for routine foot care provided by podiatric physicians. RESULTS: Analysis demonstrated that states vary dramatically in basic descriptions of preventive foot care, levels of coverage, eligibility, and methods of documenting coverage details. CONCLUSIONS: The authors recommend bringing Medicaid in line with other federal health programs and including podiatric physicians in the definition of "physician" for coverage purposes. States should move away from describing preventative services as "routine" and choose language that more accurately reflects the true nature and purpose of the care.

The Diabetic Foot-Pain-Depression Cycle.

BACKGROUND: More than 86,000 Americans with type 2 diabetes mellitus (T2DM) undergo nontraumatic lower-extremity amputations annually. The opioid-prescribing practice of podiatric surgeons remains understudied. We hypothesized that patients with T2DM who undergo any forefoot amputation while using antidepressant medication will have reduced odds of using opioids beyond 7 days. METHODS: We completed a retrospective cohort study examining patients with T2DM who underwent forefoot amputation (toe, ray, transmetatarsal). Data were restricted to patients with a hemoglobin A1c level less than 8.0% and an ankle-brachial index greater than 0.8. The outcome was use of postoperative opioids beyond 7 days. Patients received an initial opioid prescription of 7 days or less. We developed simple logistic regression models to identify the odds of a patient using opioids beyond 7 days by patient variables: age, race, sex, amputation level, body mass index, antidepressant medication use, and marital status. Variables with P < .1 in the univariate analysis were included in the multiple logistic regression model. RESULTS: Fifty patients met the inclusion criteria. Antidepressant use and marital status were the only statistically significant variables. Adjusting for marital status, patients with antidepressant use had decreased odds (odds ratio, 0.018; 95% confidence interval, 0.001-0.229; P = .002) of using opioids beyond 7 days after a diabetic forefoot amputation. CONCLUSIONS: Patients with T2DM who used antidepressants had significantly reduced odds of using opioids beyond 1 week after forefoot amputations compared with those without antidepressant use. We proposed an underlying diabetic foot-pain-depression cycle. To break the cycle, podiatric surgeons should screen this population for depression preoperatively and postoperatively and not hesitate to make a mental health referral if warranted. Nontraumatic amputations can be a traumatic experience for patients; psychiatrists and other mental health providers should be members of limb preservation teams.

Cognitive Bias in Postoperative Opioid-Prescribing Practice.

BACKGROUND: Given that excess opioid prescriptions contribute to the US opioid epidemic and there are few national opioid-prescribing guidelines for the management of acute pain, it is pertinent to determine whether prescribers can sufficiently assess their own prescribing practice. We investigated podiatric surgeons' ability to evaluate whether their own opioid-prescribing practice is less than, near, or above that of an "average" prescriber. METHODS: We administered a scenario-based, voluntary, anonymous, online questionnaire consisting of five surgery-based scenarios commonly performed by podiatric surgeons. Respondents were asked the quantity of opioids they would prescribe at the time of surgery. Respondents were also asked to rate their prescribing practice compared with the average (median) podiatric surgeon. We compared self-reported behavior to self-reported perception ("I prescribe less than average," "I prescribed about average," and "I prescribe more than average"). Analysis of variance was used for univariate analysis among the three groups. We used linear regression to adjust for confounders. Data restriction was used to account for restrictive state laws. RESULTS: One hundred fifteen podiatric surgeons completed the survey in April 2020. Less than half of the time, respondents accurately identified their own category. Consequently, there were no statistically significant differences among podiatric surgeons who reported that they "prescribe less," "prescribe about average," and "prescribe more." Paradoxically, there was a flip in scenario 5: respondents who reported they "prescribe more" actually prescribed the least and respondents who believed they "prescribe less" actually prescribed the most. CONCLUSIONS: Cognitive bias, in the form of a novel effect, occurs in postoperative opioid-prescribing practice; in the absence of procedure-specific guidelines or an objective standard, podiatric surgeons, more often than not, were unaware of how their own opioid-prescribing practice measured up to that of other podiatric surgeons.

Outcomes of Partial Calcanectomy in an Academic Limb Salvage Center: A Multicenter Review.

Chronic nonhealing heel ulcerations have been established as an independent risk factor for major amputation, with poor rates of limb salvage success. Partial calcanectomy is a controversial limb salvage procedure reserved for patients with these heel ulcerations. We conducted a retrospective cohort study reviewing 39 limbs that underwent a partial calcanectomy from 2012 to 2018 to evaluate the proportion of patients healed, time to healing, ulcer recurrence, and postoperative functional level compared to the preoperative state. In addition, age, gender, body mass index, smoking status, coronary artery disease, diabetes mellitus, renal insufficiency, dialysis, peripheral arterial disease, method of closure, and percent of calcaneus resected were evaluated. Mean follow-up for our cohort was 2.3 years. We had a 1 year mortality rate of 11%, and a major amputation rate of 18%. Our results demonstrated a 77% healing rate with a median time to healing of 162 days. We found that patients who were closed primarily had a faster time to healing compared to patients who underwent closure by secondary intention. Our data showed that ulcer recurrence developed in 57% of healed limbs. We found that 76% of our patients were ambulatory postoperatively. These results suggest that partial calcanectomy is a viable limb salvage procedure with a predictable level of ambulation and function in a high-risk patient population.

Toenail Dust as a Potential Occupational Hazard in Podiatric Medicine: A Comprehensive Literature Review.

BACKGROUND: Debridement of toenails is a common procedure that leads to the production of nail dust aerosols in the work environment. Previous studies indicate that inhaled nail dust can cause respiratory distress and eye irritation. This comprehensive review aimed to assess the available literature on the effect of nail dust exposure and to evaluate nail dust as a potential occupational hazard for podiatric physicians. METHODS: A comprehensive literature search was conducted via PubMed, Google Scholar, CINAHL, Cochrane Library, and ClinicalTrials.gov. Risks of bias of the collected studies were evaluated using various assessment tools to match the type of study design. A qualitative analysis of the included studies was performed, from which primary and secondary outcome measures were extracted: prevalence of symptoms and specific microorganisms in nail dust. RESULTS: Of 403 articles screened, eight met the inclusion criteria. The primary outcome measure resulted in a pooled prevalence of eye-related symptoms being the most consistent symptom reported (41%-48%). The secondary outcome measure resulted in a pooled prevalence of Trichophyton rubrum (9.52%-38%) and Aspergillus (11.11%-35.48%) as the most common microorganisms present in nail dust. CONCLUSIONS: From the included eight articles, we found that nail dust is a potential occupational hazard, especially for those exposed more often. Aspergillus and T rubrum are most commonly associated with nail dust leading to development of respiratory illness. It is important to take preventive measures in podiatric medical clinics by using improved and efficient personal protective equipment for workers exposed to nail dust. Detailed health safety guidelines can be developed to decrease respiratory symptoms and diseases from nail dust exposure.

An Evaluation of Real-world Smart Sock-Based Temperature Monitoring Data as a Physiological Indicator of Early Diabetic Foot Injury: Case-Control Study.

BACKGROUND: Lower extremity complications of diabetes represent major health care complications both in terms of cost and impact to quality of life for patients with diabetic peripheral neuropathy. Temperature monitoring has been shown in previous studies to provide a useful signal of inflammation that may indicate the early presence of a foot injury. OBJECTIVE: In this study, we evaluated the temperature data for patients that presented with a diabetic foot injury while using a sock-based remote temperature monitoring device. METHODS: The study abstracted data from patients who were enrolled in a remote temperature monitoring program (2020-2021) using a smart sock (Siren Care). In the study cohort, a total of 5 participants with a diabetes-related lower extremity injury during the study period were identified. In the second comparison cohort, a total of 26 patients met the criteria for monitoring by the same methods but did not present with a diabetes-related podiatric lower extremity injury during the same period. The 15-day temperature differential between 6 defined locations on each foot was the primary outcome measure among subjects who presented with a diagnosed foot injury. Paired t tests were used to compare the differences between the two groups. RESULTS: A significant difference in temperature differential (temperature measured in °F) was observed in the group that presented with a podiatric injury over the course of evaluation versus the comparator group that did not present with a podiatric injury. The average difference from all 6 measured points was 1.4 °F between the injury group (mean 3.6, SD 3.0) and the comparator group (mean 2.2, SD 2.5, t=-71.4, df=39; P<.001). CONCLUSIONS: The results of this study suggest temperature monitoring in a sock form factor could be used to predict a developing foot injury. The continuous temperature monitoring system employed has implications for further algorithm development to enable early detection. The study was limited by a nonrandomized, observational design with limited injuries present in the study period. We look forward to further studies that will refine the predictive potential and confirm or refute the current promising data.

Utilization of a Smart Sock for the Remote Monitoring of Patients With Peripheral Neuropathy: Cross-sectional Study of a Real-world Registry.

BACKGROUND: Remote patient monitoring (RPM) devices are increasingly being used in caring for patients to reduce risks of complications. Temperature monitoring specifically has been shown in previous studies to provide a useful signal of inflammation that may help prevent foot ulcers. OBJECTIVE: In this cross-sectional study, we evaluated utilization data for patients who were prescribed smart socks as remote temperature monitoring devices. METHODS: This study evaluated data from a patient registry from January to July 2021. The utilization data, which were collected starting from the first full month since patients were prescribed the smart socks, were evaluated along with retention over time, the average time that the socks were worn, and the number of days that the socks were worn per month and per week. RESULTS: A total of 160 patients wore the smart sock RPM device for 22 to 25 days per month on average. The retention rate was 91.9% (147/160) at the end of the 7-month period; a total of 13 patients were lost to follow-up during this period. The average number of days that the socks were worn per week was 5.8. The percentage of patients with a utilization rate of >15 days ranged from 79.7% (106/133) to 91.9% (125/136) each month. CONCLUSIONS: This study shows a high level of utilization for a smart sock RPM device and a high compliance rate. A future prospective study on the clinical outcomes after the use of the smart socks may further solidify the idea of conducting temperature monitoring for foot ulcer prevention.

Functional ambulatory status as a potential adjunctive decision-making tool following wound, level of ischemia, and severity of foot infection assessment.

The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System has been developed to stratify amputation risk on the basis of extent of the wound, level of ischemia, and severity of foot infection (WIfI). However, there are no currently validated metrics to assess, grade, and consider functional status, especially ambulatory status, as a major consideration during limb salvage efforts. Therefore, we propose an adjunct to the current WIfI system to include the patient's ambulatory functional status after initial assessment of limb threat. We propose a functional ambulatory score divided into grade 0, ambulation outside the home with or without an assistive device; grade 1, ambulation within the home with or without an assistive device; grade 2, minimal ambulation, limbs used for transfers; and grade 3, a person who is bed-bound. Adding ambulatory function as a supplementary assessment tool can guide clinical decision making to achieve optimal future functional ambulatory outcome, a patient-centered goal as critical as limb preservation. This adjunct may aid limb preservation teams in rapid, effective communication and clinical decision making after initial WIfI assessment. It may also improve efforts toward patient-centered care and functional ambulatory outcome as a primary objective. We suggest a score of functional ambulatory status should be included in future trials of patients with chronic limb-threatening ischemia.

Correction: Disparities in outcomes of patients admitted with diabetic foot infections.

[This corrects the article DOI: 10.1371/journal.pone.0211481.].

Disparities in outcomes of patients admitted with diabetic foot infections.

OBJECTIVE: The purpose of this study was to evaluate the disparities in the outcomes of White, African American (AA) and non-AA minority (Hispanics and Native Americans (NA)), patients admitted in the hospitals with diabetic foot infections (DFIs). RESEARCH DESIGN AND METHODS: The HCUP-Nationwide Inpatient Sample (2002 to 2015) was queried to identify patients who were admitted to the hospital for management of DFI using ICD-9 codes. Outcomes evaluated included minor and major amputations, open or endovascular revascularization, and hospital length of stay (LOS). Incidence for amputation and open or endovascular revascularization were evaluated over the study period. Multivariable regression analyses were performed to assess the association between race/ethnicity and outcomes. RESULTS: There were 150,701 admissions for DFI, including 98,361 Whites, 24,583 AAs, 24,472 Hispanics, and 1,654 Native Americans (NAs) in the study cohort. Overall, 45,278 (30%) underwent a minor amputation, 9,039 (6%) underwent a major amputation, 3,151 underwent an open bypass, and 8,689 had an endovascular procedure. There was a decreasing incidence in major amputations and an increasing incidence of minor amputations over the study period (P < .05). The risks for major amputation were significantly higher (all p<0.05) for AA (OR 1.4, 95%CI 1.4,1.5), Hispanic (OR 1.3, 95%CI 1.3,1.4), and NA (OR 1.5, 95%CI 1.2,1.8) patients with DFIs compared to White patients. Hispanics (OR 1.3, 95%CI 1.2,1.5) and AAs (OR 1.2, 95%CI 1.1,1.4) were more likely to receive endovascular intervention or open bypass than Whites (all p<0.05). NA patients with DFI were less likely to receive a revascularization procedure (OR 0.6, 95%CI 0.3, 0.9, p = 0.03) than Whites. The mean hospital length of stay (LOS) was significantly longer for AAs (9.2 days) and Hispanics (8.6 days) with DFIs compared to Whites (8.1 days, p<0.001). CONCLUSION: Despite a consistent incidence reduction of amputation over the past decade, racial and ethnic minorities including African American, Hispanic, and Native American patients admitted to hospitals with DFIs have a consistently significantly higher risk of major amputation and longer hospital length of stay than their White counterparts. Native Americans were less likely to receive revascularization procedures compared to other minorities despite exhibiting an elevated risk of an amputation. Further study is required to address and limit racial and ethnic disparities and to further promote equity in the treatment and outcomes of these at-risk patients.

Initial Report on the Use of In-Office Cone Beam Computed Tomography for Early Diagnosis of Osteomyelitis in Diabetic Patients.

Osteomyelitis is one of the most feared sequelae of diabetic foot ulceration, which often leads to lower-extremity amputation and disability. Early diagnosis of osteomyelitis increases the likelihood of successful treatment and may limit the amount of bone resected, preserving ambulatory function. Although a variety of techniques exist for imaging the diabetic foot, standard radiography is still the only in-office imaging modality used today. However, radiographs lack sensitivity and specificity, making it difficult to diagnose bone infection at its early stages. In this report, we describe our initial experience with a cone beam computed tomography (CBCT)-based device, which may serve as an accurate and readily available tool for early diagnosis of osteomyelitis in a patient with diabetes. Two patients with infected diabetic foot ulcers were evaluated for osteomyelitis using radiography and CBCT. Positive imaging findings were confirmed by bone biopsy. In both patients, CBCT captured early osteolytic changes that were not apparent on radiographs, leading to early surgical intervention and successful treatment. The CBCT was helpful in facilitating detection and early clinical intervention for osteomyelitis in two diabetic patients with foot ulcers. These results are encouraging and warrant future evaluation.

Medical and Economic Impact of a Free Student-Run Podiatric Medical Clinic A Preliminary Analysis.

BACKGROUND: Data from the free student-run podiatric medical clinic at Clínica Tepati at the University of California, Davis, were used to analyze medical and economic impacts on health-care delivery and to extrapolate the economic impact to the national level. Clínica Tepati also provides an excellent teaching environment and services to the uninsured Hispanic population in the Greater Sacramento area. METHODS: In this analysis, we retrospectively reviewed patient medical records for podiatric medical encounters during 15 clinic days between November 2010 and February 2012. The economic impact was evaluated by matching diagnoses and treatments with Medicare reimbursement rates using International Classification of Diseases codes, Current Procedural Terminology codes, and the prevailing Medicare reimbursement rates. RESULTS: Sixty-three podiatric medical patients made 101 visits during this period. Twenty patients returned to the clinic for at least one follow-up visit or for a new medical concern. Thirty-nine different diagnoses were identified, and treatments were provided for all 101 patient encounters/visits. Treatments were limited to those within the clinic's resources. This analysis estimates that $17,332.13 worth of services were rendered during this period. CONCLUSIONS: These results suggest that the free student-run podiatric medical clinic at Clínica Tepati had a significant medical and economic impact on the delivery of health care at the regional level, and when extrapolated, nationally as well. These student-run clinics also play an important role in medical education settings.