07/17/2013    Alan Sherman, DPM

Setting the Record Straight on Debridment of Calluses in Diabetics

Are amputations caused by podiatrists? 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. DiabetesCare, the well-
respected journal of the American Diabetes
Association, this past April 2013, republished
the letter.

The misinformation in this letter has been
reproduced enough, and I think it’s time that it
be corrected. Here is the letter:
http://care.diabetesjournals.org/content/36/4/e48.
full

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 the calluses form in areas of sustain 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.

I believe the best response this very public
exercise in bad judgment by Dr. Bernstein is a
letter to the editor to DiabetesCare, both by our
official body, the APMA, but also by each of us
so inclined. They need to hear the voice of good
judgment on this issue. They've already heard the
rest.

Alan Sherman, DPM, CEO, PRESENT e-Learning
Systems, asherman@presentelearning.com

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07/22/2013    Jon Purdy, DPM

Setting the Record Straight on Debridment of Calluses in Diabetics (Alan Sherman, DPM)

Here is the letter I sent to Dr. Bernstein. I
would think others may want to use it as a
template and possibly send it to The journal’s
Editor in Chief, William T. Cefalu, MD. I am
amazed that he would let such slander be printed.

Dr. Bernstein,

I have read your unscientific and misleading
observations as you presented them in your ADA
Diabetes Care piece. I challenge you to show me
statistically where podiatrist’s paring of
calluses are the leading cause of ulcerations and
morbidity in the diabetic population.

You make some valid points in advising the
offloading of pressure areas. This is not
always “readily accomplished” in patients with
significant or rigid deformities. It is a non-
covered service by Medicare absent a diagnosis of
diabetes, and for patients with diabetes and only
Medicare is only covered at 80%. Most other
insurances do not cover it at all.

Have you ever stopped to consider that any out of
pocket treatments that would prevent future
ulceration are routinely declined by the patient?
Or, that these prescribed treatments are commonly
not adhered to by the non-compliant patient?

I see many insensate patients that come to my
clinic with what they think is just a callus
which ultimately turns out to be a callus
covering an existing ulcerative site.

I can’t tell you how many times I have seen
surgeons and other physicians debride non-
infected ulcerations in avascular patients
leading to larger ulcerative areas, infections,
and amputation.

Your statement of diabetic ulcerations caused by
podiatrists in “every case” no doubt undermines
your credibility, as this is an impossible
scenario. For you to publically write something
defamatory about an entire profession without any
data, and only basing it on a patient’s side of
the story, is at the very least unprofessional.

Jon Purdy, DPM, New Iberia, LA,
jpurdy@mindspring.com