Roosevelt Warm Springs Institute for Rehabilitation: diabetic foot center

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Leading causes of lower extremity
amputation among persons with diabetes
Poorly fitting shoes Nerve damage Foot ulcers Infection Blood flow problems
Daily self inspection of the feet and proper care can help reduce the chance of amputation. Services are provided to any person with diabetes or any person that is at risk for diabetes.
Services
Foot Screen - identifies potential problems or nerve damage Footwear - selection and/or fabrication of appropriate
footwear, including shoes, braces and splints, to reduce abnormal pressures and assist in the healing of diabetic ulcers and fractures Education - prevention of further complications Treatment - wound, skin and nail care Total Contact Casting - a technique to remove pressure from the ulcer and allow continuation of ADLs Surgical services range from simple incision and drainage, nail procedures, and exostectomies to complex reconstructive cases utilizing fusion techniques, intramedullary nails, and external fixation devices

Complicated procedures or severe infections may require an inpatient stay; with long-term rehabilitation as an option in specialized cases such as Charcot neuroarthropathy
Treatment of Charcot fractures Second Opinion Option evaluates high risk cases in an
attempt to prevent amputation
Most elective surgery will be performed in outpatient settings in local hospitals. Minor procedures can be performed at the Diabetic Foot Center Clinic.
Capabilities
Our capabilities are enhanced through state-of-the-art tools and modalities which include:
EMED System' - computerized visual of the foot Doppler - provides evaluation of arterial insufficiency Transcutaneous Oxygen Monitor - allows more in-depth
evaluation of the healing potential in diabetes X-Ray - provides evaluation of fractures, charcot, and
bone infectron Infrared Dermal Thermometers - used to locate possible
future ulcerations Extremity Volumeters X-Ray Guided Needle Bone Biopsy

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EMED System
EMED is an electronic measurement system for recording and evaluating pressure distribution on flat and curved surfaces. This system helps to identify those patients most at risk for developing foot ulcers. The measurement method operates with capacitive sensors. The signals, produced from a maximum of 4000 pressure sensors, are displayed as a conform color picture on a monitor or on a printout from an ink jet color printer. AI; the patient walks on a sensor plate, the EMED computer transforms foot pressure points into multihued footprints, revealing points ranging from lowest pressure (white) to highest pressure (purple), which signals tissue in danger of breaking down. This foot map provides precise information on the shape of the danger spots, improving diagnostic capabilities.
A Valuable Resource
For the physician and the patient, treating a wound that refuses to heal is frustrating, time-consuming and expensive. Effective treatment usually requires a multidisciplinary approach that is rarely available to the individual physician.
The Diabetic Foot Center provides integrated care and complements and supports physicians' services. Physicians refer patients to the Diabetic Foot Center for comprehensive wound management. The center brings together a team of professionals that includes a physician with advanced training in wound

management and nursing staff trained in the care of chronic wounds. Dr. Brent Bernstein is the clinical director for the Diabetic Foot Center. He has been trained in all phases of wound care and in foot and ankle surgery. Dr. Bernstein is a Fellow of the American College of Foot and Ankle Surgeons and is board certified. The center also employs a staff of two registered nurses who are Certified Diabetic Foot Specialists, trained at Lower Extremity Amputation Prevention centers. One holds a masters level degree in nursing and the other is an enterostomal nurse.
The Diabetic Foot Center provides a diagnostic appraisal of the wound and the patient and follows up with a treatment plan. This information is communicated to the primary physician, who retains control of the patient's overall care. The Diabetic Foot Center is designed to augment the physician's ability to address a specific problem by providing wound evaluation, treatment and an established program to prevent reoccurrence.
Research
Formal research studies evaluating new treatments and protocols are an important part of the Diabetic Foot Center's commitment to reducing the burden of diabetes.

Diabetic Neuropathic Ulcer
A fifty year old female with diabetes with a chronic ulcer of greater than ten years duration and a history of multiple surgeries, including osteotomy with nonunion, ray resection, and failed free flap.
The patient came to the Diabetic Foot Center after having two previous opinions for below the knee amputation. The patient was extremely anxious about the possibility of limb loss. Mter doppler testing and a pre-operative pressure map (EMED) of the foot, a panmetatarsal head resection was offered to salvage the extremity.

Initial Ulcer

Pre-Op X-Ray

Pre-OpEMED
)01>03>06>10 >22>30 N/C:M:
Fore. [Nl 142 36%
FM8)( eN]

Post-Op Appearance

Healed Plantar Foot

Diabetic Foot Center

Referral Criteria
Patients with ulcers should be referred when they meet the following criteria: Full thickness wounds that fail to show significant improve-
ment in four weeks or complete healing in eight weeks All full thickness ulcers that involve tendon, ligament,
bone and/or joint, especially those that include abscess, osteomyelitis, necrotic tissue in the wound or gangrene of the wound or surrounding tissue Neuropathic ulcers in diabetic patients, especially those with accompanying foot deformity Ulcers with significant ischemia Venous ulcers, especially those with arterial component Ulcers in compromised patients Ulcers of unknown origin
Types of wounds treated: Diabetic Venous stasis Ischemic/Arterial Pressure/Decubitous Collagen vascular disease Other wounds that resist healing or are atypical
Pain syndromes: Swelling/redness/deep pain of unknown origin Painful peripheral neuropathy

At risk individuals: Patients with neuropathy or ischemia secondary to any disease Newly diagnosed persons with diabetes in need of education
and screening Persons with diabetes with a history of
noncompliance/complications Patients with a history of atraumatic amputation Charcot Neuroarthropathy and Fractures: Caused by
many diseases, primarily diabetes Any deformity that causes increased pressure in the
insensitive foot
Infections: Paronychialcellulitis Abcess/plantar space infections Foreign bodies/puncture wounds Necrotizing fasciitis/gangrene Osteomyelitis
To refer a patient or for additional information: Diabetic Foot Center Post Office Box IOOO
Warm Springs, Georgia 31830-0268 1-888-805-0876 . 706-655-5700 . 706-655-5705 fax
w w w. roo 5 eve 1 t r e h a b. 0 rg

Post-Op X-Ray

Post- Op EMED

The patient has had complete elimination of pre-op pain and ulceration and is able to participate in recreational activities.
She has a normal gait in tennis shoes one year post-surgically.

Diabetic Foot Center
Diabetes is a serious disease that can lead to blindness, heart attack, stroke, kidney failure and amputations. It is the fourth leading cause of death by disease in the United
States, killing more than 178,000 Americans each year.
The Diabetic Foot Center at the Roosevelt Warm Springs Institute for Rehabilitation provides outpatient services for the prevention, treatment and education of diabetes and related foot problems. Presently, there is no known
cure for diabetes, which is the number one cause of non-traumatic lower extremity amputation in the United States. Foot complications are the most common cause of hospitalization of persons with diabetes. Mter
amputation, 50% of these patients have a contralateral
amputation within two years. The three year survival rate after an amputation in a person with diabetes is only 50%, while the five year survival rate drops to 40%.
The primary goal of the Diabetic Foot Center is to reduce the risk of foot ulcers which can lead to eventual
amputation. A team of health care specialists provides a foot screen and treatment plan for foot care based on the Carville Approach, a leading center for diabetic foot care
research and treatment. The Diabetic Foot Center also serves as a second opinion option center for pre-amputation evaluation and treatment.

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Diabetic Foot Center

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ATLANTA

MANCHESTER

The mission ofthe Roosevelt Warm Springs Institute for Rehabilitation
is to empower individuals with disabilities to achieve personal independence.
ROOSEVELT
WARM SPRINGS INSTITUTE FOR REHABILITATION
Post Office Box IOOO Warm Springs, Georgia 3r830-0268 r-888-805-0876 . 706-655-5700 . 706-655-5705 fax
www.rooseveltrehab.org Serving... Living... Learning... Leading
Accredited by the Joint Commission on Accreditation of Healthcare Organizations and the Commission on Accreditation of Rehabilitation Facilities.