National Diabetes Awareness Month

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For most people, November is the time of year to begin preparing for the holiday season, but November is also National Diabetes Month.  In the United States alone, 25.8 million children and adults have diabetes.  This makes up about 8.3% of the population, and is projected to reach 21% by the year 2050.  There are millions of Americans with undiagnosed diabetes.

Many more who will eat candied apples, canned cranberries, apple and pumpkin pie, and all the turkey and stuffing they can handle; and may likely be precipitating their diabetes and obesity even further without even being aware that they have the signs/symptoms of diabetes in the first place. 

Early warning signs of the disease:

• Increased thirst
• Increased hunger (especially after eating)
• Dry mouth
• Frequent urination or urine infections
• Unexplained weight loss (even though you are eating and feel hungry)
• Fatigue (weak, tired feeling)
• Blurred vision
• Headaches

Diabetes can affect the entire body, including the foot and ankle.  Neuropathy is one of the most common complaints of diabetic patients.  Neuropathy results in damage to nerves, specifically the peripheral nerves, or nerves outside of the brain and spinal cord. Peripheral Neuropathy causes a burning or tingling sensation usually on the feet and legs, or on the arms.  This damage to the nerves is caused by excess blood glucose, or high blood sugar.  Over time excess glucose injures the walls of blood vessels that supply the nerves.  As neuropathy worsens, the ability to feel the lower extremity becomes diminished, which makes diabetics more prone to injuries that go unnoticed.  Neuropathy is the leading cause of diabetic foot ulcers.  Diabetic foot ulcers are caused from a combination of neuropathy, trauma, and deformity.  Deformities such as hammertoes, equinus (limited upward bending of the ankle), or bunions in diabetic patients are more problematic than in non-diabetic patients because of the other complications that come with diabetes.  If diabetic foot ulcers are left untreated they may end up getting infected, and even result in amputation.  Diabetic patients often have decreased circulation in the extremities due to hardening of the arteries or vessels, and this may slow healing time, which is why it’s vital for diabetic patients to take extra precautions when it comes to caring for their feet. 

Although diabetes is a life altering disease keeping a tight control on blood glucose levels can minimize complications.  Other ways to protect the feet in individuals with diabetes are by wearing special shoes made for diabetics, examining the feet daily, washing the feet and making sure to dry them completely, avoiding smoking, wearing clean, dry socks that are changed daily, and never walking barefoot.  Management of diabetes is the key to preventing complications, and for those that do not have diabetes the key to prevention is exercise, maintaining a healthy weight, and eating a well balanced diet.

Brian Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle surgery

External fixation here in Naples Florida

External fixation may look very high-tech, and maybe even scary.  However, external fixation has been used in one way or another since almost 2400 years ago.  External fixation techniques were described by Hippocrates, and were used in treating tibia fractures.  External fixation is a minimally invasive technique to reduce displaced fractures and has become a very important part of deformity correction and nonunion and pseudo arthrosis repair as well.

Jean François Malgaigne was one of the many pioneers that made advancements with external fixation devices.  In 1846, Malgaigne used a device that consisted of a clamp and four metal prongs to reduce and stabilize a fracture of the patella, or kneecap.  Following this external fixation device many other similar inventions were used to treat fractures in various locations.  In 1938, Raoul Hoffman made advancements that made external fixation even more useful, and allowed surgeons to place pins into a fracture for stabilization with guidance, while being minimally invasive.  In 1951, Dr. Gavriil A. Ilizarov developed the external fixation device that is still in use today.  Ilizarov’s fixation device consists of a metal frame that encircles the limb, and is attached to underlying bone by pins.  Threaded rods and hinges allow movement of the bone to the correct alignment.  Ilizarov’s external fixator is great because adjustments can be made without opening the fracture site, and the device provides stability. Also it can be converted to internal fixation once the soft tissues have become less swollen. 

Modern day external fixation not only provides stability to a fracture, but can also be used for soft tissue deformities, as well as other bony deformities.  External fixation is preferred when slow correction is required, and even more useful in high risk patients with vascular disease and even open fractures with high risk of infection.  The chance of getting a blood clot is lessened because with external fixation patients can be partial weight bearing, or weight bearing as tolerated following the procedure due to the stability that the fixation provides.  External fixators have been used for other bony deformities, such as Charcot, ankle arthritis, and clubfoot.  External fixation can also be used to lengthen amputated foot and toe stumps.  External fixation has definitely helped many people, but there are still some cons.  Pain and infections are two issues associated with external fixation, and rates vary depending on the extent of the procedure, and the location of the device.  External fixation devices are used by specially trained physicians and all three of the doctors at FFLC are capable of utilizing these various techniques for patients that require such interventions.  

Brian Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle surgery

Swimming and your feet

Everyone is starting to return to Florida for the seasonal upgrade in weather.  Fire up the pool warmer, and get ready to swim.

 Swimming is known for being an activity that is less damaging to the joints of the knee, foot and ankle, and can even offer a means of exercise for athletes of other sports with certain foot injuries!

Just about the worst thing a runner can hear is that they are injured and going to have to take time off from running.  Luckily, swimming can help soften this blow by offering an alternative way to get some cardiovascular activity.  Stress fractures are small fracture that occurs from excessive force on normal bone and can force runners to talk a break from running for several weeks.  For the runner with a stress fracture, swimming is often a great alternative that will not bear weight on the injury.  Swimming can also help an athlete ease back into their favorite sport after other serious injuries.  For example, after a peroneal tendon tear, swimming can help to make the transition from being immobilized in a cast or a CAM walker boot to normal running or other weight bearing sports go more gently by allowing the muscles to slowly adapt.  

Swimmers should also be careful to take care to avoid injuries that can occur from intense pool training.  Ankle pain is a common complaint from the repetitive motion the ankles are forced through while swimming.  The Achilles tendon, which is responsible for flexing the foot, may also become irritated from the repetition and develop Achilles tendonitis.  While the Achilles is doing much of the work, the extensor tendons on the top of the foot can also become irritated by being tightly pulled.  By taking care to stretch the feet and ankles properly and always listen to your body when working out, these injuries can be minimized.  Swimmers also need to take extra care to avoid developing warts, Athlete’s foot, and fungal nails from bacteria and fungus that may live in locker rooms and poolside surfaces where other bare feet have deposited them.  If these conditions do develop, see us at Family Foot and Leg Center for an urgent evaluation, as to help prevent spread to others. 

Dr Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle Surgery.

Diabetics who smoke cigarettes beware

Smoking releases a molecule known as norepinephrine, which triggers blood vessels to constrict, or narrow. When the already small vessels in the foot constrict, oxygen and the cells that fight infection and aid in healing are unable to reach tissues. Each cigarette smoked has been shown to cause oxygen levels to fall and remain low for 30 to 50 minutes. This is of great concern in those with a foot wound or incision after surgery, in which blood flow and oxygen are vital to skin healing.    

Each cigarette contains more than 4,000 natural and synthetic chemicals. Some of these chemicals include carbon monoxide, methanol (which is found in rocket fuel), ammonia, and nicotine.  Nicotine has been shown to decrease the molecules that are responsible for growth of new blood vessels and development of osteoblasts, or bone building cells. Carbon monoxide further contributes to the decrease in tissue oxygen caused by vessel constriction, by taking oxygen away from the molecule it is normally transported in in the blood. It is for these reasons that quitting smoking is imperative for individuals with foot problems. Studies have shown that there is a 2.7 times higher risk of bone not healing in smokers compared to non-smokers undergoing foot surgery.  

Prior to foot surgery involving bone, smoking should be stopped at least 6 weeks prior to the procedure if possible and then take that opportunity to stop smoking indefinitely. 

In individuals with diabetes or other disorders affecting their blood vessels, smoking is even more dangerous.  Pressure ulcers develop when sensation is diminished and the normal feeling of pain associated with a wound is not present. Tissue healing is impaired and there is a heightened risk of infection developing. Combined with smoking, such risks are furthered increased. Individuals with diabetes who notice a foot wound, whether they are smokers or not, should contact their podiatrist immediately. Early treatment can prevent infection and worsening of the wound that can potentially lead to a need for amputation.  Bill’s story in the smoking ad is a scary one, but by sharing it he may be able to prevent others from suffering a similar fate of amputation. 

The Lover's Fracture

The calcaneus bone, or heel bone, is among the most commonly fractured tarsal bone in the foot.  Calcaneus fractures account for 1-2% of fractures in the body.  

Calcaneus fractures are also known as the Lover’s fracture.  

Calcaneal fractures often occur due to a jump from a height, which is how the term “Lover’s fracture” was coined because a lover may jump from great heights to escape from a lover’s spouse or boyfriend.

Calcaneal fractures are generally traumatic fractures occurring from motor vehicle accidents, muscular stress, or falls from a height.  We usually see these injuries in worker's injury claim cases, whereby someone has fallen off of a ladder or rooftop. 

Calcaneal fractures are categorized based on whether the fracture is displaced (greater than 2mm displacement), open (with soft tissue or bony structure exposed), closed (with skin and soft tissue intact), or comminuted (3 or more pieces).  Treatment for calcaneal fractures varies based on the type of fracture.  Standard radiographs and CT scan are used to diagnose calcaneal fractures, and determine the severity of the injury.  Pain over the heel, inability to walk, or a hematoma that extends to the sole of the foot are all signs of a calcaneal fracture.  

Presence of a hematoma on the sole is known as the “Mondor Sign”.  In a non-displaced fracture nonsurgical treatment may be sufficient.  Displaced or comminuted fractures typically require surgical treatment consisting of some type of fixation with metal plates or screws or more recently we have used multiplanar external fixation for restoration of height, the angle, and joint space of the posterior facet in the subtalar joint. 

In closed fractures surgical treatment is often postponed until swelling has subsided.  In open (exposed soft tissue or bone) or avulsion fractures (when a tendon pulls off a piece of bone), more urgent treatment is required.  Open fractures are exposed to the environment and need to be cleaned and then surgically corrected within a short time period to prevent infection which is another advantage of external fixation. 

 

Minor calcaneal fractures usually heal within a few months, and cause minimal long-term limitations.  More severe fractures may take years to heal, and never return to the previous condition.  

Long-term complications may include pain, limb length discrepancies, and changes in gait with chronic swelling, and reduced endurance and strength.  

Early treatment by the foot and ankle surgeon (ie Family Foot and Leg Center)  is the key to minimizing long-term complications. 

-Dr Timm

4 Tips to Reduce Diabetes Risk

Diabetes Mellitus affects more than 230 million people worldwide!  

That is equivalent to approximately 10 times the number of people living in the state of Florida alone.  

One out of every three people with diabetes is unaware they have the disease.  

There are three types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes.  The number of Americans with diabetes is expected to double or triple by the year 2050.  While these statistics are grim, there are many things that can be done to prevent type 2 diabetes. 

Here are some simple lifestyle changes that can prevent diabetes:

• Stay at a healthy weight.  Type 2 diabetes and obesity are closely linked, and maintaining a healthy weight can really make a difference!  The goal is to maintain a BMI less than 25.
• Eating well is also important in prevention.  Surprisingly, studies have shown that women that consume processed red meat are at increased risk of developing type 2 diabetes.  Eating less meat may be preventative as well as avoiding foods high in saturated fats, cholesterol, and sugar.  Eating whole grains, nuts and citrus fruits have also shown to be preventative.  Having a diet high in fiber can also help control blood sugar, thus lowering the risk of developing diabetes.  Stay away from fad diets, and make it a goal to simply make healthier choices.
• Ditch the soda for coffee!  Drinking soda can increase your diabetes risk by 26%, but drinking more than 1 cup of coffee a day can be preventative. 
• Be active.  Walking for just a few minutes about half an hour after dinner has shown to be helpful by lowering blood sugar levels.  Weight lifting can also lower blood sugar better than aerobic exercise can, while maintaining muscle mass and speeding metabolism.  However, a good mix of aerobic exercise and weight training is ideal for maximum benefit.

These are just a few tips for a healthier lifestyle that may aid in the prevention of developing type 2 diabetes.  Type 2 diabetes has some genetic components, but developing the disease is greatly affected by lifestyle.  It is never too late to start living a healthier lifestyle, and if you are at increased risk of developing diabetes it is important to talk to your doctor and get screened for diabetes.

-Dr Timm

CROW Brace to treat severe deformity in high risk patients.

CROW - Charcot Restraint Orthotic Walker

What is a CROW Brace?

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The Charcot Restraint Orthotic Walker, or CROW, is a stable boot designed to accommodate and support a foot with Charcot neuroarthropathy. The CROW consists of a fully enclosed ankle/foot orthotic with a rocker-bottom sole.  It is a common treatment used after the acute charcot foot has calmed down.

 

What is Charcot deformity?

This occurs when bones and joints in the foot fracture, break up or pop out of place with minimal or no known direct injury. In the United States, this deformity is most commonly seen in people with diabetes. The foot first enters an acute stage of swelling, warmth and redness, which eventually diminish. Broken bones and dislocations can occur, causing severe deformities of the foot and ankle. Some patients develop pain or ulcers when the affected foot becomes deformed. CN can affect the other foot or happen again in the same foot. The foot does not regain its normal shape. 

What is a CROW made of?

The boot is custom made for each patient’s foot. The outer shell consists of two plastic or fiberglass clamshell pieces that fit and are strapped together with Velcro. It is sturdy and can prevent other bones from cracking or breaking and can be walked on. The bottom of the boot has a rounded rocker-bottom shape. The boot contains a custom, removable foam insole. Each insole is adjusted to distribute weight equally and also to support the ankle joint.

 

What does the boot do?

The CROW functions by providing even support to the entire foot, especially to areas that are overstressed due to the neuroarthropathy. These deformities often cause the foot to bend out of shape. The resulting stress on the foot can cause ulcers, which can develop into severe infections if left untreated. By distributing pressure equally throughout the leg and foot, the CROW removes excessive forces and gives the foot time to heal. It is easier to use than a cast, can be removed for wound care and washing, and is more durable.

 

Which patients can use the CROW?

Patients with acute Charcot can begin using the CROW after the swelling has receded. This can take months.  Patients with mild to moderate deformities will benefit most from the CROW. Patients with severe  deformities or extreme foot/ankle instability may need surgery instead of using the CROW.

 

How does it affect daily life?

Fortunately, the CROW is adaptable to daily life. Because of the clamshell design, the patient can easily remove the boot in order to keep the foot clean and sleep better. In addition, its fitted shape and good support allow people to return to walking, standing and driving more normally.

 

What are typical outcomes?

The most important outcome is that patients are able to continue to bear weight while minimizing pressure and giving the foot a chance to heal. Healing may require many months. However, the disease process may return and/or affect the other foot, so regular and lifelong monitoring of the condition is necessary.

 

What are the possible complications?

Despite the sturdiness of the boot and the distribution of forces, the bones of the foot could still break. The foot could develop open sores, though the boot is designed to prevent it. As always with Charcot deformity, some joints may heal incorrectly or not at all. Unfortunately, other factors such as poor glucose control and bad nutrition can prevent healing despite use of a CROW.

 

Frequently Asked Questions

What options do I have when my foot is still swollen?Patients often wear special casts until their feet stop swelling enough for them to use a CROW. The cast serves to stabilize the foot and prevent unstable motion, similar to the CROW. However, unlike the CROW, these casts cannot be removed.