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It is now 10 years since the last technical review on preventative foot care was published (1), which was followed by an American Diabetes Association (ADA) position statement on preventive foot care in diabetes (2). Many studies have been published proposing a range of tests that might usefully identify patients at risk of foot ulceration, creating confusion among practitioners as to which screening tests should be adopted in clinical practice. A task force was therefore assembled by the ADA to address and concisely summarize recent literature in this area and then recommend what should be included in the comprehensive foot exam for adult patients with diabetes. The committee was cochaired by the immediate past and current chairs of the ADA Foot Care Interest Group (A.J.M.B. and D.G.A.), with other panel members representing primary care, orthopedic and vascular surgery, physical therapy, podiatric medicine and surgery, and the American Association of Clinical Endocrinologists. The lifetime risk of a person with diabetes developing a foot ulcer may be as high as 25%, whereas the annual incidence of foot ulcers is ∼2% (3–7). Up to 50% of older patients with type 2 diabetes have one or more risk factors for foot ulceration (3,6). A number of component causes, most importantly peripheral neuropathy, interact to complete the causal pathway to foot ulceration (1,3–5). A list of the principal contributory factors that might result in foot ulcer development is provided in Table 1. View this table: Table 1— Risk factors for foot ulcers The most common triad of causes that interact and ultimately result in ulceration has been identified as neuropathy, deformity, and trauma (5). As identification of those patients at risk of foot problems is the first step in preventing such complications, this report will focus on key components of the …

The purpose of this study was to determine the elution characteristics of vancomycin and tobramycin when mixed with calcium sulfate to form antibiotic beads. Calcium sulfate was combined with vancomycin and tobramycin separately to form 2 types of antibiotic beads, which were packaged and labeled separately. The packaged calcium sulfate beads with vancomycin and tobramycin were then gas sterilized. The beads were placed in phosphate-buffered saline and kept at 36 degrees C for 6 weeks. Two separate series of assays were run simultaneously for both types of beads. In one assay, a bead containing vancomycin was placed in a fresh vial of phosphate buffered saline after each assay. The same was done with beads containing tobramycin. In the second series of assays, 9 vials of phosphate buffered saline each containing 1 vancomycin bead and 9 vials of phosphate buffered saline each containing 1 tobramycin bead was arranged. The phosphate-buffered saline was then assayed at predetermined times for both the vancomycin bead series and the tobramycin bead series. The amount of vancomycin and tobramycin assayed nearly equaled the calculated amount of antibiotic per bead measured before bead construction. Also, the elution of antibiotic from the calcium sulfate was complete within 72 hours. In conclusion, the construction and gas sterilization of calcium sulfate beads containing vancomycin and tobramycin does not destroy vancomycin and tobramycin. Also, the complete elution of available vancomycin and tobramycin in calcium sulfate beads occurs within 72 hours.

Of all superficial fungal infections, onychomycosis is the most difficult to manage. Practitioners of all disciplines realize its chronic nature, difficulty in eradication, and propensity to recur. Topical treatment of onychomycosis, as opposed to oral therapies, offers a distinct advantage by allowing the patient to apply medication directly to the affected area, thus decreasing the potential for serious adverse events, such as drug toxicity and drug interactions. In the past, a multitude of topical antifungal agents were used in the treatment of onychomycosis; however, an acceptable level of scientific evidence regarding their effectiveness was lacking and this was evident by poor success rates. The development of a comparatively effective topical agent, the only one so far to gain FDA approval, has renewed interest in this form of therapy. Improved versions are being developed that may overcome the shortcomings of the first approved topical agent.

The worldwide increase in prevalence of type 2 diabetes has resulted in a parallel increase in diabetic foot ulcers--a pervasive and significant problem associated with this disease [2]. Currently, an estimated 10.3 million people have been diagnosed with diabetes, while an additional estimated 5.4 million people with diabetes remain undiagnosed, representing a sixfold increase in the incidence of diabetes over the past four decades [9]. Approximately 15% (more than 2 million individuals, based on these estimates) of all people with diabetes will develop a lower-extremity ulcer during the course of the disease [10-12]. While most of these ulcers can be treated successfully on an outpatient basis, some will persist and become infected. Ultimately, between 14% and 20% of patients with lower-extremity diabetic ulcers will require amputation of the affected limb [13-15]. Diabetic foot ulcers can result in staggering financial burdens for both the healthcare system and the patient. For example, analysis of the 1995 Medicare claims revealed that lower-extremity ulcer care accounted for $1.45 billion in Medicare costs and contributed substantially to the high cost of care for diabetics, compared with Medicare costs for the general population [5]. Therapies that promote rapid and complete healing and reduce the need for expensive surgical procedures would impact these costs substantially. Results of this analysis suggest that becaplermin may ultimately be more cost-effective for the treatment of chronic diabetic foot ulcers than other treatment modalities, despite its higher initial dollar cost. This finding may be attributed to a combination of factors. First, expenses incurred in more prolonged treatment, such as office visits and the need for additional dressings, can be avoided when healing completes in a shorter period. Second, rapid and complete ulcer healing may reduce the incidence of significant morbidities (such as amputation or infection) and premature mortality; consequently, the financial burden associated with these complications would be reduced. Finally, the value of improved quality of life in patients with healed ulcers and the reduction in financial burden for patients who return to work cannot be ignored. These promising results warrant further investigation in larger controlled clinical studies to define more clearly the cost-effectiveness of becaplermin in this patient population.

Too many times theories of how the human foot functions and therefore how mechanically inducted foot problems are treated have been presented as if they were facts. The dogmatic adherence that sometimes ensues from such an approach has frequently stifled the evolution of foot mechanics. This has been particularly apparent in the field of podiatry which has been dominated by the Root paradigm. Briefly, the Root paradigm proposes that the human foot functions ideally around the subtalar joint’s neutral position. Additionally, the forefoot to rearfoot frontal plane relationship ideally should be perpendicular. Furthermore, deviations from those ideal positions are termed deformities. [1,2] Biomechanical treatments according to Root are intended to re-align the foot so as to function around the neutral subtalar position and/or prevent frontal plane compensations from a deformed forefoot. In essence this paradigm is based on foot morphology. Several studies have raised doubts as to the validity of the Root paradigm. [3-8] This abstract is a review of several papers which raise those doubts and explores emerging paradigms of human foot function which align more with current research findings on foot function.[9-11]