 |
|
Choosing a Practical Screening Instrument to Identify Patients at Risk for Diabetic Foot Ulceration
David G. Armstrong, DPM;
Lawrence A. Lavery, DPM, MPH;
Steven A. Vela;
Terri L. Quebedeaux, DPM;
John G. Fleischli, DPM
Arch Intern Med. 1998;158:289-292.
ABSTRACT
| |
Objective To evaluate the sensitivity and specificity of 3 sensory perception testing instruments to screen for risk of diabetic foot ulceration.
Methods This case-control study prospectively measured the degree of peripheral sensory neuropathy in diabetic patients with and without foot ulcers. We enrolled 115 age-matched diabetic patients (40% male) with a case-control ratio of approximately 1:3 (30 cases and 85 controls) from a tertiary care diabetic foot specialty clinic. Cases were defined as individuals who had an existing foot ulceration or a history of a recently (<4 weeks) healed foot ulceration. Controls were defined as subjects with no foot ulceration history. Using receiver operating characteristic analysis, we evaluated the sensitivity and specificity of 2 commonly used neuropathy assessment tools (vibration perception threshold testing and the Semmes-Weinstein 10-g monofilament wire system) and a 4-question verbal neuropathy score to evaluate for presence of foot ulceration.
Results A vibration perception threshold test using 25 V and lack of perception at 4 or more sites using the Semmes-Weinstein 10-g monofilament wire system had a significantly higher specificity than the neuropathy score used. The neuropathy score was most sensitive when 1 or more answers were affirmative. When modalities were combined, particularly the monofilament wire system plus vibration perception threshold testing and the neuropathy score plus the monofilament wire system, there was a substantial increase in specificity with little or no diminution in sensitivity.
Conclusions The early detection of peripheral neuropathy or loss of "protective sensation" is paramount to instituting a structured treatment plan to prevent lower extremity amputation. The results of our study suggest that all 3 sensory perception testing instruments are sensitive in identifying patients at risk for ulceration. Combining modalities appears to increase specificity with very little or no diminution in sensitivity.
INTRODUCTION
THE MORBIDITY, direct cost, and mortality associated with lower extremity complications among patients with diabetes mellitus have been well described in the medical literature.1-6 Peripheral sensory neuropathy is one of the strongest risk factors for both foot ulceration and amputation in this population.7-8 In the absence of neuropathy, people rarely develop foot ulcers. Because of the lack of painful feedback, peripheral neuropathy provides a permissive environment that allows repetitive tissue injury to occur such that a person may wear a hole in the bottom of his or her foot much in the way that he or she may wear a hole in a stocking. Certainly, the early detection of a level of peripheral neuropathy sufficient to contribute to the development of foot wounds or "loss of protective sensation"9 is one of the most important criteria to identify high-risk patients for foot complications and is paramount when instituting a structured treatment plan to prevent lower extremity complications.10-12
The notion that neuropathy is generally necessary to produce a diabetic foot ulcer has been well established. However, the methods of testing to identify loss of protective sensation along the spectrum of neuropathy have been quite variable and ill defined. In an attempt to provide a simple, inexpensive, and reliable means of testing for the absence of protective sensation, the Semmes-Weinstein monofilament wire system (SW) has been widely advocated as a screening tool. Several reports have discussed the potential clinical use of monofilaments, particularly the 10-g monofilament, in identifying patients at risk for foot ulceration.9, 13-15 Additionally, measurement of the vibration perception threshold (VPT) using a simple handheld tactor is another popular method for establishment of a threshold for protective sensation.10, 16 Finally, some investigators have measured specific subjective symptoms and included them in the overall assessment of protective sensation.17 While all these studies support the notion that these instruments may be clinically useful, inconsistent testing methods, different sites of testing on the foot, and various recommendations for interpreting the data have contributed to confusion. Furthermore, many of these studies have reported sensitivity and specificity data with very small sample sizes and in some cases, no control group for comparison.9, 14, 18-19 The purpose of this study was to evaluate the sensitivity and specificity of 3 simple, commonly used sensory perception testing instruments to screen for risk of diabetic foot ulceration.
SUBJECTS, MATERIALS, AND METHODS
This project was conducted as a case-control study with 115 age-matched diabetic patients (40% male) with a case-control ratio of approximately 1:3 (30 cases and 85 controls). Further descriptive subject characteristics are listed in Table 1. Cases were defined as subjects who had an existing or recently (<4 weeks) healed foot ulceration. Controls were defined as subjects with no foot ulceration history. We evaluated the sensitivity and specificity of 2 commonly used neuropathy assessment tools and a simple questionnaire. These included VPT testing, which was measured using a biothesiometer (Biomedical Instrument Corporation, Newbury, Ohio), and the SW system (North Coast Medical, San Jose, Calif). These devices have been shown to have very high intrarater and interrater reliability.16, 20 The University of Texas Subjective Peripheral Neuropathy verbal questionnaire included 4 queries to identify the presence of burning, formication, numbness, and paresthesias:
|
|
|
|
Table 1. Descriptive Patient Characteristics
|
|
|
Do your feet ever feel numb?
Do your feet ever tingle, as if electricity were traveling into your foot?
Do your feet ever feel as if insects were crawling on them?
Do your feet ever burn?
A positive answer to any 1 of the 4 verbal questions constituted 1 point. A negative answer constituted 0 points.
The instrument used to conduct the VPT testing was a handheld device with a rubber tactor that vibrates at 100 Hz. The handheld unit was connected by an electrical cord to a base unit. This unit contains a linear scale that displays the applied voltage, ranging from 0 to 50 V. The method of testing was standardized. The device was held with the tactor balanced vertically on the pulp of the toe. At this time, the voltage was increased on the base unit until the patient could perceive a vibration. A mean of 3 readings (measured in volts) was used to determine the VPT for each foot.10
The SW testing was performed using a standard yes-no method of administration. This method instructed the patient to say yes each time he or she perceived the application of the monofilament. Measurements were taken at each of 10 sites on the foot,21 including the plantar aspects of the first, third, and fifth digits; the plantar aspects of the first, third, and fifth metatarsal heads; the plantar medial and lateral sides of the midfoot; the plantar area of the heel; and the dorsal aspect of the midfoot. Additionally, we evaluated the sensitivity and specificity of a subjective neuropathy score (NS). For purposes of analysis, we used 4 different VPT cutoff points (15, 20, 25, and 30 V), 5 different SW cutoff points (inability to perceive 1-5 sites), and 4 questionnaire cutoff points (1-4 positive responses) to evaluate the most effective level at which to identify foot ulcer risk. For selecting the optimal diagnostic cutoff points on the scale of measurement, receiver operating characteristics curves were used.22-23
RESULTS
All 3 modalities used to evaluate sensory perception were sensitive to detect patients at risk of ulceration. The sensitivity and specificity of the 10-g monofilament, the neuropathy questionnaire, and the VPT are illustrated in Figure 1, Figure 2, and Figure 3, respectively. When the 10-g monofilament was evaluated, specificity increased with little change in sensitivity as the number of sites that could not be perceived increased up to 4 imperceptible sites. We noticed a significant decrease in sensitivity and specificity when we moved beyond 5 imperceptible sites. The sensitivity of the neuropathy questionnaire was 100% when we used 1 or more positive answers as a criterion for loss of protective threshold (NS1), but it decreased dramatically as the cutoff point for positive answers increased, with only a mild increase in specificity. Vibration perception threshold testing using the biothesiometer showed a steady increase in specificity with little change in sensitivity until 25 V, above which there was a significant decrease in sensitivity. Overall, VPT testing and 4 or more imperceptible sites using the monofilament wire (SW4) had significantly higher specificity than the verbal neuropathy questionnaire. When modalities were combined, particularly SW4 plus VPT and NS1 plus SW4, there was a substantial increase in specificity with little or no diminution in sensitivity. These data are outlined in Table 2.
|
|
|
|
Figure 1. The sensitivity and specificity of Semmes-Weinstein 10-g monofilament wire, plotted as a receiver operating characteristics curve.
|
|
|
|
|
|
|
Figure 2. The sensitivity and specificity of the neuropathy questionnaire, plotted as a receiver operating characteristics curve.
|
|
|
|
|
|
|
Figure 3. The sensitivity and specificity of vibration perception threshold, plotted as a receiver operating characteristics curve. The threshold was measured at 15, 20, 25, and 30 V.
|
|
|
|
|
|
|
Table 2. Neuropathy Testing Instruments in Combination*
|
|
|
COMMENT
The results of our study suggest that all 3 sensory perception testing methods are sensitive in identifying patients at risk for foot ulceration. Combining modalities appears to increase specificity with very little or no diminution in sensitivity. Previous studies have identified that both SW and VPT are reliable and reproducible measurements. However, we have been unable to identify any other reports that have compared modalities in a large group of patients with and without wounds that specifically detail the method of measurement and reported the sensitivity and specificity of these instruments. Furthermore, this is the first report in the medical literature, to our knowledge, that reports on a marriage of simple peripheral sensory testing modalities to screen for risk of diabetic neuropathic ulceration. It appears that, while all these modalities are relatively sensitive, a combination of modalities, particularly the SW4 plus VPT and NS1 plus SW4, provides increased specificity with little or no diminution in sensitivity.
Neuropathy is the most important component in the causal pathway to diabetic ulceration, lower extremity amputation, and Charcot arthropathy. Yet despite its critical clinical importance, the technique for measuring peripheral sensory neuropathy and, more importantly, loss of sensory protective threshold has received little attention in the majority of physical diagnosis texts.24-26 It has been reported that basic physical examination skills may not improve significantly beyond graduation from medical school.27 Therefore, it may be inferred that many physicians, having not been exposed to techniques to evaluate the presence of sensory protective threshold in persons with diabetes mellitus early in their training, may never develop these skills. We have noted that, of patients admitted to a university teaching hospital with diabetes-related foot pathological findings, less than 15% receive a minimally competent lower extremity examination, which includes evaluation of sensory protective threshold.28
Since peripheral sensory neuropathy is a pivotal element in the causal pathway to both foot ulceration and amputation, selecting a quick, inexpensive, and accurate instrument to evaluate the high-risk patient is essential to make decisions about the allocation and distribution of medical resources and personnel. Allocation of appropriate intervention modalities in high-risk diabetic patients has been shown to decrease the rate of reulceration by up to 60% and lower extremity amputation by up to 85%.29-31 However, intervention in this patient population is expensive. In a health care system saddled with limited resources and charged with serving an aging population with an increasing prevalence of chronic diseases (such as diabetes), it is important to identify high-risk patients to allocate resources and implement aggressive medical care in populations in which they will have the greatest impact. In this era of expensive high-tech gadgetry, it is exciting to identify a situation where common sense, a bit of patient history, and simple tools provide essential medical information. The instruments described in this article offer an inexpensive and reliable method that can be easily incorporated by nurses, primary care physicians, or specialists into clinical practice. These tests can be performed relatively quickly (in <5 minutes) at regular intervals (eg, every 6 months). By identifying patients at risk, these "low-tech" instruments may have the most profound impact in the eventual implementation of appropriately directed care and the subsequent reduction of diabetes-related lower extremity amputations.
AUTHOR INFORMATION
Accepted for publication June 3, 1997.
Corresponding author: David G. Armstrong, DPM, Department of Orthopaedics, University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78284-7776.
From the Department of Orthopaedics, University of Texas Health Science Center (Drs Armstrong, Lavery, Quebedeaux, and Fleischli and Mr Vela), The Diabetic Foot Research Group (Drs Armstrong, Lavery, and Fleischli), and the Mexican American Medical Treatment Effectiveness Research Center (Dr Lavery), San Antonio, Tex.
REFERENCES
| |
1. Lavery LA, Ashry HR, van Houtum W, Pugh JA, Harkless LB, Basu S. Variation in the incidence and proportion of diabetes-related amputations in minorities. Diabetes Care. 1996;19:48-52.
ABSTRACT
2. van Houtum WH, Lavery LA, Harkless LB. The impact of diabetes-related lower-extremity amputations in the Netherlands. J Diabetes Complications. 1996;10:325-330.
FULL TEXT
|
ISI
| PUBMED
3. van Houtum WH, Lavery LA, Harkless LB. The costs of diabetes-related lower extremity amputations in the Netherlands. Diabet Med. 1995;12:777-781.
ISI
| PUBMED
4. Armstrong DG, Lavery LA, van Houtum WH, Harkless LB. The impact of gender on amputation. J Foot Ankle Surg. 1997;36:66-69.
PUBMED
5. Armstrong DG, Lavery LA, Harkless LB, van Houtum WH. Amputation and reamputation of the diabetic foot. J Am Podiatr Med Assoc. 1997;87:255-259.
ABSTRACT
6. Armstrong DG, Lavery LA, van Houtum WH, Harkless LB. Seasonal variations in lower extremity amputation. J Foot Ankle Surg. 1997;36:146-150.
PUBMED
7. McNeely MJ, Boyko EJ, Ahroni JE, et al. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. Diabetes Care. 1995;18:216-219.
ABSTRACT
8. Pecoraro RE, Reiber GE, Burgess EM. Causal pathways to amputation: basis for prevention. Diabetes Care. 1990;13:513-521.
ABSTRACT
9. Birke JA, Sims DS. Plantar sensory threshold in the ulcerated foot. Lepr Rev. 1986;57:261-267.
ISI
| PUBMED
10. Young MJ, Breddy JL, Veves A, Boulton AJM. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. Diabetes Care. 1994;16:557-560.
ABSTRACT
11. Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR. The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic. Diabet Med. 1997;14:357-363.
FULL TEXT
|
ISI
| PUBMED
12. Armstrong DG, Lavery LA, Quebedeaux TL, Walker SC. Surgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus non-diabetic adults. South Med J. 1997;90:384-389.
ISI
| PUBMED
13. Olmos PR, Cataland S, O'Dorisio TM, Casey CA, Smead WL, Simon SR. The Semmes-Weinstein monofilament as a potential predictor of foot ulceration in patients with non-insulin dependent diabetes. Am J Med Sci. 1995;309:76-82.
ISI
| PUBMED
14. Holewski JJ, Stess RM, Graf PM, Grunfeld C. Aesthesiometry: quantification of cutaneous pressure sensation in diabetic peripheral neuropathy. J Rehabil Res Dev. 1988;25:1-10.
15. Mueller MJ, Diamond JE, Delitto A, Sinacore DR. Insensitivity, limited joint mobility, and plantar ulcers in patients with diabetes mellitus. Phys Ther. 1989;69:453-462.
16. Bloom S, Till S, Sönsken P, Smith S. Use of a biothesiometer to measure individual vibration thresholds and their variation in 519 non-diabetic subjects. BMJ. 1984;288:1793-1795.
17. Dyck PJ. Detection, characterization, and staging of polyneuropathy: assessed in diabetics. Muscle Nerve. 1988;11:21-32.
FULL TEXT
|
ISI
| PUBMED
18. Valk GD, de Sonnaville JJ, van Houtum WH, et al. The assessment of diabetic polyneuropathy in daily clinical practice: reproducibility and validity of Semmes-Weinstein monofilaments examination and clinical neurological examination. Muscle Nerve. 1997;20:116-118.
FULL TEXT
|
ISI
| PUBMED
19. Kumar S, Fernando DJS, Veves A, Knowles EA, Young MJ, Boulton AJM. Semmes-Weinstein monofilaments: a simple, effective and inexpensive screening device for identifying diabetic patients at risk of foot ulceration. Diabetes Res Clin Pract. 1991;13:63-68.
FULL TEXT
|
ISI
| PUBMED
20. Diamond JE, Mueller MJ, Delitto A, Sinacore DR. Reliability of a diabetic foot evaluation. Phys Ther. 1989;69:797-802.
21. Mueller MJ. Identifying patients with diabetes who are at risk for lower extremity complications: use of Semmes-Weinstein monofilaments. Phys Ther. 1996;76:68-71.
FREE FULL TEXT
22. Bortheiry AL, Malerbi DA, Franco LJ. The ROC curve in the evaluation of fasting capillary blood glucose as a screening test for diabetes and IGT. Diabetes Care. 1994;11:1269-1272.
23. Tsuji L, Nakamoto K, Hasegawa T, Gohdes DM, Inawashiro H, Fukao A. Receiver operating characteristic analysis on fasting plasma glucose, HbA1c, and fructosamine on diabetes screening. Diabetes Care. 1992;14:1075-1077.
ABSTRACT
24. Swartz MH, ed. Physical Diagnosis. Philadelphia, Pa: WB Saunders Co; 1989:73-82.
25. DeGowin RL. DeGowin and DeGowin's Diagnostic Examination. 6th ed. New York, NY: McGraw-Hill Book Co, Health Professions Division; 1994.
26. Greenberger DR. History Taking and Physical Examination: Essentials and Clinical Correlates. St Louis, Mo: Mosby–Year Book Inc; 1993.
27. Nishikawa J, Sackett DL. Do fundamental clinical skills improve beyond graduation from medical school? Clin Res. 1989;37:525. Abstract.
28. Edelson GW, Armstrong DG, Lavery LA, Caicco G. The acutely infected diabetic foot is not adequately evaluated in an inpatient setting. Arch Intern Med. 1996;156:2373-2376.
ABSTRACT
29. Edmonds ME. Experience in a multidisciplinary diabetic foot clinic. In: Connor H, Boulton AJM, Ward JD, eds. The Foot in Diabetes. New York, NY: John Wiley & Sons Inc; 1987:121-131.
30. Edmonds ME, Blundell MP, Morns ME, Thomas EM, Cotton LT, Watkins PJ. Improved survival of the diabetic foot: the role of a specialized foot clinic. QJM. 1986;60:763-771.
FREE FULL TEXT
31. Apelqvist J, Ragnarson-Tennval G, Persson U, Larsson J. Diabetic foot ulcers in a multidisciplinary setting: an economic analysis of primary healing and healing with amputation. J Intern Med. 1994;235:463-471.
ISI
| PUBMED
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Prevalence and Risk Factors for Neuropathy in a Canadian First Nation Community
Bruce and Young
Diabetes Care 2008;31:1837-1841.
ABSTRACT
| FULL TEXT
The Relationship of Reduced Peripheral Nerve Function and Diabetes With Physical Performance in Older White and Black Adults: The Health, Aging, and Body Composition (Health ABC) Study
Strotmeyer et al.
Diabetes Care 2008;31:1767-1772.
ABSTRACT
| FULL TEXT
Comprehensive Foot Examination and Risk Assessment: A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists
Boulton et al.
Diabetes Care 2008;31:1679-1685.
FULL TEXT
Improving Foot Self-Care Behaviors With Pies Sanos
Borges and Ostwald
West J Nurs Res 2008;30:325-341.
ABSTRACT
A Case Report of the Treatment of Diabetic Foot Ulcers Using a Sodium Hyaluronate and Iodine Complex
Sobotka et al.
INT J LOW EXTREM WOUNDS 2007;6:143-147.
ABSTRACT
Risk Factors for Recurrent Diabetic Foot Ulcers: Site matters
Peters et al.
Diabetes Care 2007;30:2077-2079.
FULL TEXT
Scottish Foot Ulcer Risk Score Predicts Foot Ulcer Healing in a Regional Specialist Foot Clinic
Leese et al.
Diabetes Care 2007;30:2064-2069.
ABSTRACT
| FULL TEXT
Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis: Reliable or relic?
Lavery et al.
Diabetes Care 2007;30:270-274.
ABSTRACT
| FULL TEXT
Preventing Diabetic Foot Ulcer Recurrence in High-Risk Patients: Use of temperature monitoring as a self-assessment tool
Lavery et al.
Diabetes Care 2007;30:14-20.
ABSTRACT
| FULL TEXT
Do US Veterans Wear Appropriately Sized Shoes?: The Veterans Affairs Shoe Size Selection Study.
Nixon et al.
J. Am. Podiatr. Med. Assoc. 2006;96:290-292.
ABSTRACT
| FULL TEXT
Risk Factors for Foot Infections in Individuals With Diabetes.
Lavery et al.
Diabetes Care 2006;29:1288-1293.
ABSTRACT
| FULL TEXT
Testing for Loss of Protective Sensation in Patients with Foot Ulceration: A Cross-sectional Study
Wood et al.
J. Am. Podiatr. Med. Assoc. 2005;95:469-474.
ABSTRACT
| FULL TEXT
Back to Basics in Diagnosing Diabetic Polyneuropathy With the Tuning Fork!
Meijer et al.
Diabetes Care 2005;28:2201-2205.
ABSTRACT
| FULL TEXT
Evaluation of Removable and Irremovable Cast Walkers in the Healing of Diabetic Foot Wounds: A randomized controlled trial
Armstrong et al.
Diabetes Care 2005;28:551-554.
ABSTRACT
| FULL TEXT
Preventing Foot Ulcers in Patients With Diabetes
Singh et al.
JAMA 2005;293:217-228.
ABSTRACT
| FULL TEXT
A Validation Study of a Self-Administered Questionnaire to Identify Increased Risk for Foot Ulceration or Amputation Among People With Diabetes
Valente et al.
The Diabetes Educator 2004;30:932-944.
Variability in Activity May Precede Diabetic Foot Ulceration
Armstrong et al.
Diabetes Care 2004;27:1980-1984.
ABSTRACT
| FULL TEXT
Plantar Soft-Tissue Thickness Predicts High Peak Plantar Pressure in the Diabetic Foot
Abouaesha et al.
J. Am. Podiatr. Med. Assoc. 2004;94:39-42.
ABSTRACT
| FULL TEXT
Skin Temperatures as a One-time Screening Tool Do Not Predict Future Diabetic Foot Complications
Armstrong et al.
J. Am. Podiatr. Med. Assoc. 2003;93:443-447.
ABSTRACT
| FULL TEXT
Diabetic Foot Syndrome: Evaluating the prevalence and incidence of foot pathology in Mexican Americans and non-Hispanic whites from a diabetes disease management cohort
Lavery et al.
Diabetes Care 2003;26:1435-1438.
ABSTRACT
| FULL TEXT
Predictive Value of Foot Pressure Assessment as Part of a Population-Based Diabetes Disease Management Program
Lavery et al.
Diabetes Care 2003;26:1069-1073.
ABSTRACT
| FULL TEXT
Comorbidities Associated with Diabetic Foot Complications Among Asian Americans in Southern California
Han et al.
J. Am. Podiatr. Med. Assoc. 2003;93:37-41.
ABSTRACT
| FULL TEXT
Ankle Equinus Deformity and Its Relationship to High Plantar Pressure in a Large Population with Diabetes Mellitus
Lavery et al.
J. Am. Podiatr. Med. Assoc. 2002;92:479-482.
ABSTRACT
| FULL TEXT
Evaluation of Pressure Threshold Prior to Foot Ulceration: One- versus Two-Point Static Touch
Barber et al.
J. Am. Podiatr. Med. Assoc. 2001;91:508-514.
ABSTRACT
| FULL TEXT
Continuous Activity Monitoring in Persons at High Risk for Diabetes-Related Lower-Extremity Amputation
Armstrong et al.
J. Am. Podiatr. Med. Assoc. 2001;91:451-455.
ABSTRACT
| FULL TEXT
Functional Status of Persons With Diabetes-Related Lower-Extremity Amputations
Peters et al.
Diabetes Care 2001;24:1799-1804.
ABSTRACT
| FULL TEXT
Effectiveness of the Diabetic Foot Risk Classification System of the International Working Group on the Diabetic Foot
Peters and Lavery
Diabetes Care 2001;24:1442-1447.
ABSTRACT
| FULL TEXT
A Prospective Study of Predictors for Foot Ulceration in Type 2 Diabetes
Kastenbauer et al.
J. Am. Podiatr. Med. Assoc. 2001;91:343-350.
ABSTRACT
| FULL TEXT
Plantar Tissue Thickness Is Related to Peak Plantar Pressure in the High-Risk Diabetic Foot
Abouaesha et al.
Diabetes Care 2001;24:1270-1274.
ABSTRACT
| FULL TEXT
Passage of Policy Statement on the High Risk of Blindness, Lower-Extremity Amputations, and Oral Health Consequences in Minority Populations Due to Diabetes
Robbins and Holland
J. Am. Podiatr. Med. Assoc. 2001;91:313-315.
FULL TEXT
Off-Loading the Diabetic Foot Wound: A randomized clinical trial
Armstrong et al.
Diabetes Care 2001;24:1019-1022.
ABSTRACT
| FULL TEXT
Simple Screening Tests for Peripheral Neuropathy in the Diabetes Clinic
Perkins et al.
Diabetes Care 2001;24:250-256.
ABSTRACT
| FULL TEXT
Improvement in Healing With Aggressive Edema Reduction After Debridement of Foot Infection in Persons With Diabetes
Armstrong and Nguyen
Arch Surg 2000;135:1405-1409.
ABSTRACT
| FULL TEXT
Arthrodesis as an Early Alternative to Nonoperative Management of Charcot Arthropathy of the Diabetic Foot
SIMON et al.
JBJS 2000;82:939-939.
ABSTRACT
| FULL TEXT
Factors Associated with Bone Regrowth Following Diabetes-Related Partial Amputation of the Foot
ARMSTRONG et al.
JBJS 1999;81:1561-5.
ABSTRACT
| FULL TEXT
Lengthening of the Achilles Tendon in Diabetic Patients Who Are at High Risk for Ulceration of the Foot
ARMSTRONG et al.
JBJS 1999;81:535-8.
ABSTRACT
| FULL TEXT
Elevated Peak Plantar Pressures in Patients Who Have Charcot Arthropathy
ARMSTRONG and LAVERY
JBJS 1998;80:365-9.
ABSTRACT
| FULL TEXT
|
