A position statement by controversial low-carb guru Richard Bernstein, MD has been circulating in various forms since August 2012, blaming all foot amputations in patients with diabetes on debridement of calluses.
This past April 2013, Diabetes Care, the well-respected journal of the American Diabetes Association, republished the letter. The misinformation in this letter has been reproduced enough, and I think it’s time that it be corrected. Here is a link to the letter: Letter by Bernstein in April 2013 DiabetesCare.
The issue is his sweeping generalization and ridiculous misquoted statistics. Bernstein calls the debridement of calluses in patients with diabetes “the primary causes or initiative events that led to foot ulcerations.” He states that in patients with a unilateral amputation, when he asks those patients for the cause of the amputation, “In every case, it has been an attempt to grind down or remove a callus, usually by a podiatrist….”
Certainly injuries leading to amputations have been caused by surgeons, cosmetologists and podiatrists, and by the patients themselves. But we know how often ulcerations and abscesses are found under thick dystrophic calluses in the feet of patients with diabetes. We know that in insensate feet, pressure necrosis occurs in any area with sustained high pressure. And we know that thick calluses exacerbate the injury in areas of sustained high pressure. Of course, pressure necrosis occurs in areas where callus forms, and of course, the pressure is reduced by the removal of the callus. Should thin, flexible calluses be removed? Probably not…many factors should be considered. Should thick, dystrophic, rigid calluses be removed? Of course they should, and they should be removed as atraumatically as possible. What has more relative danger in an ambulatory patient with diabetes with significant neuropathy: leaving a thick callus or removing it? It depends on how likely it is that it can be removed atraumatically. Podiatrists do not typically “grind down a callus…with a pumice stone,” as Dr. Bernstein states. They use surgical cutting instruments, often followed by mild dermabrasion, carefully avoiding friction related heat buildup.
In a recent review of such cases, almost all patient who have had BK amputations had recently visited a vascular surgeon and had a CTA. Does that mean that I should advise my patients to be staying away from vascular surgeons? Of course not… coincidence does not necessarily equal cause, and podiatrists do not generally cause amputations.
In fact, trimming of calluses is one tiny part of how today’s podiatrists are caring for the feet of patients with diabetes and associated neuropathy. Read the Journal of Diabetic Foot Complications
, attend the Desert Foot Conference
or the other high quality wound care conferences and you will learn that podiatrists are protecting insensate feet from injury and saving diabetic feet by the thousands with wounds that would have lead to immediate amputation 20 years ago.
I believe Dr. Bernstein’s advice to the diabetic limb care community simply represents bad advice unsupported by evidence, perhaps born of prejudice, ignorance and limited experience working with today’s well trained podiatrists. Your audience needs to hear the voice of good judgment on this issue if we are to give our patients with diabetes and neuropathy the best care possible.
Alan Sherman, DPM, CCMEP
CEO, PRESENT e-Learning Systems