Neuropathic Diabetic Foot Research Articles

Monitoring of pH and temperature of neuropathic diabetic and nondiabetic foot ulcers for 12 weeks: An observational study.

Wound bed assessment is largely reliant on subjective interpretation without recourse to objective tools or biomarkers. The identification of a point of care, reliable biomarker would enhance assessment and ultimately clinical decision making. Two potentially emerging wound biomarkers exist: surface pH and surface temperature. To date, knowledge of their use has been predominantly in wound prevention, in vitro studies and single time measurements. Our objective was to determine surface pH, size, and surface temperature in noninfected, neuropathic foot ulcers at baseline and at 12 weeks. 50 patients (68% [n = 34] had diabetes) participated. Mean baseline pH of wounds was 6.95 (SD 1.01); temperature 30.91°C (SD 3.00); and size 0.82 cm2 (SD 0.61). After 12 weeks, 26% (n = 13) were lost to follow-up, 50% (n = 25) had healed. Of the remaining patients, mean pH was 6.72 (SD 0.54); temperature 30.88°C (SD 2.97), and size 0.13 cm2 (SD 0.13). We have provided baseline values for pH and temperature of noninfected, neuropathic diabetic, and nondiabetic foot ulceration. Further studies in a larger cohort are warranted to determine if temperature and or pH are indicative of a healing or nonhealing state.

An exploratory study on differences in cumulative plantar tissue stress between healing and non-healing plantar neuropathic diabetic foot ulcers

BackgroundMechanical stress is important in causing and healing plantar diabetic foot ulcers, but almost always studied as peak pressure only. Measuring cumulative plantar tissue stress combines plantar pressure and ambulatory activity, and better defines the load on ulcers. Our aim was to explore differences in cumulative plantar tissue stress between people with healing and non-healing plantar diabetic foot ulcers. MethodsWe analyzed a subgroup of 31 patients from a randomized clinical trial, treated with a removable offloading device for their plantar diabetic forefoot ulcer. We measured in-device dynamic plantar pressure and daily stride count to calculate cumulative plantar tissue stress at the ulcer location and associated this with ulcer healing and ulcer surface area reduction at four weeks (Student's t and chi-square test for significance, Cohen's d for effect size). FindingsIn 12 weeks, 68% (n = 21) of the ulcers healed and 32% (n = 10) did not. No statistically significant differences were found for cumulative plantar tissue stress, plantar pressure or ambulatory activity between people with healed and not-healed ulcers. Cumulative plantar tissue stress was 25% lower for people with healed ulcers (155 vs. 207 MPa·s/day; P = 0.71; Effect size: d = 0.29). Post-hoc analyses in the 27 patients who self-reported to be adherent to wearing the device showed that cumulative plantar tissue stress was 49% lower for those who reached ≥75% ulcer surface area reduction at four weeks (140 vs. 275 MPa·s/day; P = 0.09; d = 0.76); smaller differences and effect sizes were found for peak pressure (24%), peak pressure-time integral (30%) and ambulatory activity (26%); (P-value range: 0.14–0.97; Cohen's d range: 0.14–0.70). InterpretationMeasuring cumulative plantar tissue stress may provide insight beyond that obtained from plantar pressure or ambulatory activity alone, with regard to diabetic foot ulcer healing using removable offloading devices. These explorative findings provide baseline data for further studies on this relevant topic.

Surgical Management of Diabetic Neuropathy Foot Complications.

Background: Diabetic foot complications result from the association between peripheral vascular disease, neuropathy and a precarious healing process. Peripheral neuropathy observed in diabetics affects all components of the nervous system, contributing to the occurrence of leg ulcers, musculoskeletal changes, resulting in severe deformities. The clinical manifestation of these complications ranges from simple lesions to complex entities threatening the loss of pelvic limb or even life (1,2). Methods: In our surgery department, a significant number of patients with diabetic foot lesions are hospitalized and treated annually, 40% having clinical manifestations of diabetic neuropathy associated. In 2017, a total of 448 patients were hospitalized for complications of diabetes. We performed a retrospective analysis of 150 consecutive patients who underwent surgery for neuropathic diabetic foot lesions. Results: The analyzed patients had a favorable postoperative progression, benefiting from distal perfusion. Ray resection was the preferred surgical intervention. Major amputation was performed in 10% of cases with extensive gangrene and sepsis, amputation of the calf being preferred in all situations. Conclusions: The management of these patients is delicate, often multidisciplinary approach being necessary. A well-managed therapeutic attitude can make the difference between preserving or losing the pelvic limb.

Wound Management In Diabetic Foot Ulcer (DFU) - Incremental Cost-Analysis Of Treating Diabetic Neuropathic Foot Lesions With Adjunct Hemoglobin Contact Spray In Germany

Wound Management In Diabetic Foot Ulcer (DFU) - Incremental Cost-Analysis Of Treating Diabetic Neuropathic Foot Lesions With Adjunct Hemoglobin Contact Spray In Germany

Diabetic neuropathic foot ulcer: Metatarsal osteotomy for surgical off-loading

Diabetic neuropathic foot ulcer: Metatarsal osteotomy for surgical off-loading

Оценка клинико-морфологических особенностей заживления язвенных дефектов при синдроме диабетической стопы

Aim. To assess the clinical and morphological characteristics of neuropathic diabetic foot ulcers (DFUn) Materials and Methods. Forty-three specimens of DFUn were analysed. Depending on the outcome, samples were divided into 2 groups: group 1—healed ulcers (30 samples), group 2—unhealed ulcers (13 samples). The following characteristics were analysed: age, sex, glycated haemoglobin (HbA1c), ulcer duration, time of admission to the specialised clinic, severity of neuropathy, presence of late complications, plantar localisation, percentage of necrotic tissue, granulation and fibrotic tissue and, Ki-67expression. Results. Patients were similar in age, HbA1c, severity of late complications and plantar localisation. There was a significant difference in the time of admission to the specialised clinic [50 vs 132 days, p = 0.03], percentage of granulation [61 ± 25 vs 32 ± 21 %, р = 0.001] and fibrotic tissue [24 ± 24 vs 49 ± 22 %, р = 0.002], the granulation/fibrosis coefficient [7.5 ± 8.1 vs 1.9 ± 4.6 (%), р = 0,02] and expression of Ki-67 [15 ± 8 vs ± 21 (%), р = 0.001] between groups. A multidimensional model revealed granulation tissue as the main parameter influencing healing. The probability of healing was 1.0 if the percentage of granulation tissue was 7%, the probability of healing was 0.75. For Ki-67 levels ≤7%, the probability of healing was 0.17 and the probability of not healing was 0.83. Conclusion. The time at which a patient was admitted to the specialised clinic and the percentage of granulation tissue were key factors affecting the prognosis of wound healing in DFUn.

Clinical and morphological characteristics of wound healing in diabetic foot syndrome

Aim. To assess the clinical and morphological characteristics of neuropathic diabetic foot ulcers (DFUn)
 Materials and Methods.Forty-three specimens of DFUn were analysed. Depending on the outcome, samples were divided into 2 groups: group 1healed ulcers (30 samples), group 2unhealed ulcers (13 samples). The following characteristics were analysed: age, sex, glycated haemoglobin (HbA1c), ulcer duration, time of admission to the specialised clinic, severity of neuropathy, presence of late complications, plantar localisation, percentage of necrotic tissue, granulation and fibrotic tissue and, Ki-67expression.
 Results. Patients were similar in age, HbA1c, severity of late complications and plantar localisation. There was a significant difference in the time of admission to the specialised clinic [50 vs 132 days, p = 0.03], percentage of granulation [61 25 vs 32 21 %, р = 0.001] and fibrotic tissue [24 24 vs 49 22 %, р = 0.002], the granulation/fibrosis coefficient [7.5 8.1 vs 1.9 4.6 (%), р = 0,02] and expression of Ki-67 [15 8 vs 21 (%), р = 0.001] between groups. A multidimensional model revealed granulation tissue as the main parameter influencing healing. The probability of healing was 1.0 if the percentage of granulation tissue was 50%. If the percentage of granulation tissue was 50%, the prognosis of healing was determined by the expression of Ki-67. When Ki-67 levels were 7%, the probability of healing was 0.75. For Ki-67 levels 7%, the probability of healing was 0.17 and the probability of not healing was 0.83.
 Conclusion. The time at which a patient was admitted to the specialised clinic and the percentage of granulation tissue were key factors affecting the prognosis of wound healing in DFUn.

Comparison of Metatarsal Head Resection Versus Conservative Care in Treatment of Neuropathic Diabetic Foot Ulcers

Complications from diabetic foot ulcers often lead to increased patient morbidity. Much debate still ensues concerning surgical versus conservative management of neuropathic diabetic foot ulcerations. The present study assessed and compared the efficacy of metatarsal head resection and medical approach in the treatment of neuropathic diabetic foot ulcers located at the plantar surface of metatarsal heads. In a retrospective cohort study, 24 consecutive neuropathic diabetic foot ulcers in the lower area of the metatarsal heads that had undergone metatarsal head resection were included as the operative group. For the control group, we included 25 similar ulcers that were scheduled for medical therapy. With respect to postoperative complications, wound healing occurred earlier in the operative group, and the recurrence rate was inversely greater in the medical treatment group. Also, the hospitalization rate was significantly greater in the medical treatment group. Overall, the long-term complication rate was lower in the operative than in the medical treatment group. Also, the infection rate was greater in the medical treatment group than in the operative group. Comparing early and late clinical outcomes of metatarsal head resection surgery and medical treatment showed complete superiority for the surgical approach, and metatarsal head resection is more completely cost beneficial than the medical approach.

Effects of weight-bearing exercise on a mini-trampoline on foot mobility, plantar pressure and sensation of diabetic neuropathic feet; a preliminary study.

ABSTRACT Objective: Foot and ankle exercise has been advocated as a preventative approach in reducing the risk of foot ulceration. However, knowledge about the appropriate types and intensity of exercise program for diabetic foot ulcer prevention is still limited. The current study aimed to examine the effects of an eight-week mini-trampoline exercise on improving foot mobility, plantar pressure and sensation of diabetic neuropathic feet. Methods: Twenty-one people with diabetic peripheral neuropathy who had impaired sensation perception were divided into two groups. The exercise group received a foot-care education program plus an eight-week home exercise program using the mini-trampoline (n = 11); whereas a control group received a foot-care education only (n = 10). Measurements were undertaken at the beginning, at the completion of the eight-week program and at a 20-week follow-up. Results: Both groups were similar prior to the study. Subjects in the exercise group significantly increased the range of the first metatarsophalangeal joint in flexion (left: p = 0.040, right: p = 0.012) and extension (left: p = 0.013) of both feet more than controlled subjects. There was a trend for peak plantar pressure at the medial forefoot to decrease in the exercise group (p = 0.016), but not in the control group. At week 20, the number of subjects in the exercise group who improved their vibration perception in their feet notably increased when compared to the control group (left: p = 0.043; right: p = 0.004). Conclusions: This is a preliminary study to document the improvements in foot mobility, plantar pressure and sensation following weight-bearing exercise on a flexible surface in people with diabetic neuropathic feet. Mini-trampoline exercise may be used as an adjunct to other interventions to reduce risk of foot ulceration. A larger sample size is needed to verify these findings. This trial is registered with COA No. 097.2/55.

Healing of Neuropathic Diabetic Foot Ulcers of PEDIS Grade 1-2 at Home Care with Topical Antiseptics: An Observational Follow-Up Investigation

Objective: This observational and clinical prospective follow-up study examined the healing of ordinary diabetic foot ulcers at home-care setting with two commercially available topical antiseptics, one in formulation as a solution and the other one as a salve. Method: The study population consisted of 35 consecutive adult outpatients with diabetic foot ulcers that were classified as grades 1-2 by using the PEDIS (Perfusion, Extent, Depth, Infection and Sensation) classification system. The patients were treated by two commercial antiseptics (Abilar® 10% Resin Salve or Octenidine® solution) and followed-up by a specialized clinic with four follow-up visits during a treatment period of 145 days on average. All patients performed the wound care at home after instructions from the clinic. Results: At study entry, the mean ulcer area was 221 mm2 (median 140 mm2, interquartile range: 73-320 mm2) in the salve group and 277 mm2 (median 132 mm2, interquartile range: 50–365 mm2) in the solution group. In intentto- treat (ITT) analysis of the whole study population of 35 patients, the ulcers healed totally in 14 (37%; 95% CI 24-56%), and in 9 of 19 patients (47%; 95% CI: 25%-77%) and in 5 of 16 patients (31%; 95% CI: 9%-54%) in the resin salve and Octenidine solution groups, respectively (P>0.05). The infected ulcer with small median size showed an insignificant trend to heal better than the other ulcers. The number of positive bacterial cultures from ulcers (bacteria of Staphylococcus and Streptococcus species in great majority of cases), taken on clinical grounds if infection was suspected, was lower in follow-up visits than at study entry. No side effects were observed. Conclusion: Treatment of diabetic foot ulcers of PEDIS grade 1-2 at home-care with topical antiseptics is an option that results in complete healing of ulcer in more than one third of cases in a 145-day treatment period.

The Effectiveness of Three Layers Foam Dressing as an Offloading Technique in Treating Diabetic Foot Ulcer : Comparative Study

Background and aim of the work: and aim of the work: More than 25% of Saudi Arabia population are diabetics, about 20% of the will develop ulcer in their feet. Offloading is the cornerstone in prevention or healing of plantar neuropathic foot ulcers. This study aimed to investigate the effectiveness of use of three layers elastic foam as an off-loading modality in patients with diabetic non infected neuropathic ulcers in term of the speed of healing progress and comparing that with removable walking boat off-loading techniques. Patients and methods: this prospective double-blind, randomized, controlled clinical trialwas done in diabetic foot care clinics at King Abdul Aziz specialist Hospital, King Faisal general Hospital and Prince Mansour military Hospital, Taif, Saudi Arabia from January 2014 to October 2016.Diabetic patients with non infected neuropathic plantar ulcers after debridement of at least 2 weeks were included in the study. Ischemic ulcers are excluded from the study. Patients who met the inclusion criteria of this study weresubdevided randomized into 2 groups, the felted foam dressings group; in which the three layers felted foam was applied around the ulcer. Control group the removable walking boat was used. In both groups the ulcer was covered with saline soaked dressing to be changed daily. Results:47 patients were enrolled in the study (23 in felted foam group and 24 in the removable walking boat group). There was no significant difference in the demographics, ulcer size, duration of diabetes, and clinical and laboratory data between both groups (P > 0.05). The mean duration of complete healing of the ulcer was highly significantly shorter in felted foam group than in the removable walking boat group (P < 0.001). In both groups the duration of healing was negatively correlated with the patient age, the level of HbA1c,andthe ulcer size (P < 0.05). Conclusions: the three layers felted foam is effective, simple, and less expensive offloading technique and it superior to removable walking boat in promoting the complete healing of neuropathic diabetic foot ulcers.

Evaluation of tissue engineering products for the management of neuropathic diabetic foot ulcers: an interim analysis.

The objective of this prospective, multicentre clinical study is to assess the application of MatriStem MicroMatrix (MSMM) and MatriStem Wound Matrix (MSWM) (porcine urinary bladder derived extracellular matrix) compared with Dermagraft (DG) (human fibroblast-derived dermal substitute) for the management of non-healing diabetic foot ulcers (DFUs). A randomised, multicentre study was conducted at thirteen centers throughout the US. It was designed to evaluate the incidence of ulcer closure, rate of ulcer healing, wound characteristics, patient quality of life, cost-effectiveness, and recurrence. Those subjects whose DFUs decreased in size by ≤30% or increased by ≤50% during the standard of care (SOC) phase were randomised into the treatment phase of the study. The study evaluated complete wound closure by eight weeks with weekly device application. A two-week post treatment SOC phase followed the treatment phase for any wounds that did not heal by the end of eight weeks, and wound closure was also evaluated at the end of that period. Ulcer recurrence at 6 months post-treatment was evaluated in the subjects that showed wound healing by the end of the post-treatment SOC phase. Standard adjunctive therapy, including debridement, saline irrigation and foot off-loading, was provided to both arms during the four-week screening period, after which eligible subjects were randomised in a 1:1 ratio, to either the MatriStem (MS) or DG treatment arm. This study was developed to evaluate the hypothesis that the wound outcomes observed after wound management with MS were non-inferior to those of DG after eight weeks. The authors present the planned interim results of this study after one half of the projected enrolment was completed. There were 95 subjects consented and entered into the SOC four-week screening phase of the trial and 56 were randomised into the treatment phase. At the planned interim analysis, there was a significantly lower cost per subject and significant improvement in patient quality of life for the subjects treated with MS compared with those managed with DG. However, there was not a statistically significant difference found during the analysis of the interim data between the two study groups for rate of wound healing or number of subjects with complete wound closure. The data from this interim analysis show that MSMM and MSWM provide results for healing DFUs that are similar to the results obtained for DG at a significant quality of life and economic advantage. The opinions expressed are those of the authors and not necessarily those of the Department of Veterans Affairs or the United States Government. T.W. Gilbert is employed as the Chief Science Officer and is a stockholder in ACell, Inc., which commercializes MatriStem Wound Matrix and MicroMatrix. None of the other authors have a conflict of interest to declare.

Evaluation of tissue engineering products for the management of neuropathic diabetic foot ulcers: an interim analysis

The objective of this prospective, multicentre clinical study is to assess the application of MatriStem MicroMatrix (MSMM) and MatriStem Wound Matrix (MSWM) (porcine urinary bladder derived extracellular matrix) compared with Dermagraft (DG) (human fibroblast-derived dermal substitute) for the management of non-healing diabetic foot ulcers (DFUs). A randomised, multicentre study was conducted at thirteen centers throughout the US. It was designed to evaluate the incidence of ulcer closure, rate of ulcer healing, wound characteristics, patient quality of life, cost-effectiveness, and recurrence. Those subjects whose DFUs decreased in size by ≤30% or increased by ≤50% during the standard of care (SOC) phase were randomised into the treatment phase of the study. The study evaluated complete wound closure by eight weeks with weekly device application. A two-week post treatment SOC phase followed the treatment phase for any wounds that did not heal by the end of eight weeks, and wound closure was also evaluated at the end of that period. Ulcer recurrence at 6 months post-treatment was evaluated in the subjects that showed wound healing by the end of the post-treatment SOC phase. Standard adjunctive therapy, including debridement, saline irrigation and foot off-loading, was provided to both arms during the four-week screening period, after which eligible subjects were randomised in a 1:1 ratio, to either the MatriStem (MS) or DG treatment arm. This study was developed to evaluate the hypothesis that the wound outcomes observed after wound management with MS were non-inferior to those of DG after eight weeks. The authors present the planned interim results of this study after one half of the projected enrolment was completed. There were 95 subjects consented and entered into the SOC four-week screening phase of the trial and 56 were randomised into the treatment phase. At the planned interim analysis, there was a significantly lower cost per subject and significant improvement in patient quality of life for the subjects treated with MS compared with those managed with DG. However, there was not a statistically significant difference found during the analysis of the interim data between the two study groups for rate of wound healing or number of subjects with complete wound closure. The data from this interim analysis show that MSMM and MSWM provide results for healing DFUs that are similar to the results obtained for DG at a significant quality of life and economic advantage.

Factors predicting a foot ulcer in the diabetic neuropathic foot

Fibromyalgia is a prevalent musculoskeletal disorder characterized by chronic widespread pain that significantly reduces quality of life in patients. Due to the lack of consistently effective treatment, the development of improved therapies for treating fibromyalgia is necessary. As dysfunction of serotonergic analgesic control appears to be involved in the pathophysiology of fibromyalgia, the present study explored the potential of 5-HT2C receptor agonists as novel therapies for treating this disease. Three 5-HT2C receptor agonists (lorcaserin, vabicaserin and YM348) that have been suggested to be useful in the treatment of several central nervous system diseases, including obesity and schizophrenia, were used. The effect of systemic administration of these agents on the muscular hyperalgesia that develops in the reserpine-induced myalgia (RIM) rat, a putative animal model of fibromyalgia, was investigated. RIM rats exhibited decreased muscle pressure thresholds. Microdialysis experiments showed that the concentration of serotonin (5-HT) in the spinal cord of RIM rats was significantly lower than that of controls. Lorcaserin (0.3–3 mg/kg p.o.), vabicaserin (0.3–3 mg/kg s.c.) and YM348 (0.03–0.3 mg/kg p.o.) recovered the muscle pressure threshold. The effect of lorcaserin was reversed by the pretreatment with SB242084, a 5-HT2C receptor antagonist. Our findings demonstrate that 5-HT2C receptors play a critical role in muscular hyperalgesia in RIM rats and suggest that 5-HT2C receptor agonists have therapeutic potential for treating chronic pain in patients with fibromyalgia although clinical extrapolation remains to be a future challenge.

Prospective study on microangiopathy in type 2 diabetic foot ulcer

We investigated the significance of microangiopathy in the development of foot ulcer, which is still disputed. We assessed microangiopathy by histological analysis of the capillary ultrastructure using transmission electron microscopy and capillary density and arteriolar morphology in paraffin-embedded sections from the skin of type 2 diabetic patients: 30 neuroischaemic patients (Isc) revascularised with peripheral angioplasty and 30 neuropathic patients (Neu) with foot ulcer, compared with ten non-diabetic volunteers. In the diabetic patients, capillaries in the dermal papillary layer were fewer (-22.2%, 159 ± 43 vs 205 ± 52mm(2) in non-diabetic volunteers, p < 0.01). They also showed detrimental remodelling, with a 2.2-fold increase in capillary basement membrane thickness (3.44 ± 1.19 vs 1.53 ± 0.34μm in non-diabetic volunteers, p < 0.001) and a 57.7% decrease in lumen area (14.6 ± 11.1 vs 34.7 ± 27.5μm(2), p < 0.001). No differences were observed between the diabetic Isc or Neu patients. Isc were more prone to develop arteriolar occlusion than Neu (16.8 ± 6.9% vs 6.7 ± 3.7%, respectively, p < 0.001). No patient had been amputated at 30days and healing time was significantly longer in Isc (180 ± 120 vs 64 ± 50days in Neu, p < 0.001). Capillary microangiopathy is present in equal measure in neuroischaemic and neuropathic diabetic foot skin. The predominance of arteriolar occlusions with neuroischaemia indicated the existence of an additional 'small vessel disease' that did not affect an effective revascularisation and did not worsen the prognosis of major amputations but slowed the healing process of the neuroischaemic foot ulcer. ClinicalTrials.gov NCT02610036.

Foot Temperature Trends in Normal, Diabetic, and Neuropathic Foot Populations

INTRODUCTION AND OBJECTIVES: Patients with underlying peripheral neuropathy are subject to changes in foot temperature. (1,2) Of the many forms of neuropathy that affect the lower extremity, the most notable are those types associated with diabetes. The aim of this study was to look for differences in temperatures between uncomplicated diabetic, diabetic neuropathic, and non-diabetic neuropathic feet. METHODS: The feet of 75 subjects were divided into 3 groups: 1) normal (n=50 feet), 2) diabetic (n=50 feet), and 3) neuropathic (n=49 feet). The neuropathic group was further subdivided into diabetic neuropathies (n=20 feet) and non-diabetic neuropathies (n=29 feet). To properly assign subjects to groups, all participants underwent vibratory threshold testing with a biothesiometer. In addition, all diabetic subjects had added glycosylated hemoglobin (hemoglobin A1C) studies performed. Temperature measurements were recorded at nine distinct foot locations (six plantar and three dorsal). Data was statistically analyzed using the Kruskal-Wallis test. RESULTS: For five of the plantar pedal sites tested, temperatures in the diabetic foot were significantly greater than those for the normal controls (p&amp;lt;0.05). At most sites, temperatures in the diabetic foot population tended to be higher than those in both diabetic and non-diabetic neuropathic feet, with the differences between the diabetic foot and non-diabetic neuropathic foot being statistically significant at one dorsal and five plantar sites. Patients in the non-diabetic neuropathic group were not stratified according to their specific neuropathic types. CONCLUSIONS: Diabetic feet, with and without neuropathy, tend to be warmer than the feet of patients with other non-diabetic neuropathies. The finding of no statistical difference between non-neuropathic diabetic and neuropathic diabetic feet is unexpected in that a number of these patients were projected to have an autonomic system component. These null findings suggest the need to further investigate neuropathy solely determined by sensory testing versus tests for autonomic system involvement.

Diabetic neuropathic foot and ankle instability

Diabetic neuropathic foot and ankle instability

The prevention of diabetic foot ulceration: how biomechanical research informs clinical practice.

ABSTRACTBackgroundImplementation of interprofessional clinical guidelines for the prevention of neuropathic diabetic foot ulceration has demonstrated positive effects regarding ulceration and amputation rates. Current foot care recommendations are primarily based on research regarding the prevention of ulcer recurrence and focused on reducing the magnitude of plantar stress (pressure overload). Yet, foot ulceration remains to be a prevalent and debilitating consequence of Diabetes Mellitus. There is limited evidence targeting the prevention of first-time ulceration, and there is a need to consider additional factors of plantar stress to supplement current guidelines.ObjectivesThe first purpose of this article is to discuss the biomechanical theory underpinning diabetic foot ulcerations and illustrate how plantar tissue underloading may precede overloading and breakdown. The second purpose of this commentary is to discuss how advances in biomechanical foot modeling can inform clinical practice in the prevention of first-time ulceration.DiscussionResearch demonstrates that progressive weight-bearing activity programs to address the frequency of plantar stress and avoid underloading do not increase ulceration risk. Multi-segment foot modeling studies indicate that dynamic foot function of the midfoot and forefoot is compromised in people with diabetes. Emerging research demonstrates that implementation of foot-specific exercises may positively influence dynamic foot function and improve plantar stress in people with diabetes.ConclusionContinued work is needed to determine how to best design and integrate activity recommendations and foot-specific exercise programs into the current interprofessional paradigm for the prevention of first-time ulceration in people with Diabetes Mellitus.

Muscle and Joint Factors Associated With Forefoot Deformity in the Diabetic Neuropathic Foot.

Diabetic forefoot joint deformities are a known risk factor for skin breakdown and amputation, but the causes of deformity are not well understood. The purposes of this study were to determine the effects of intrinsic foot muscle deterioration and limited ankle joint mobility on the severity of metatarsophalangeal joint (MTPJ) deformity, and determine the relationships between these potential contributing factors and indicators of diabetic complications (peripheral neuropathy and advanced glycation end products). A total of 34 participants with diabetic neuropathy (average age, 59 years; range 41-73) were studied. MTPJ angle and intrinsic foot muscle deterioration were measured with computed tomography and magnetic resonance imaging, respectively. Maximum ankle dorsiflexion was measured using kinematics. Skin intrinsic fluorescence served as a proxy measure for advanced glycation end product accumulation. Total forefoot lean muscle volume (r = -0.52, P < .01) and maximum ankle dorsiflexion (r = -0.42, P < .05) were correlated with severity of MTPJ deformity. Together they explained 35% of the variance of MTPJ angle. Neuropathy was correlated with forefoot muscle deterioration (ρ = 0.53, P < .01). Skin intrinsic fluorescence was correlated to severity of neuropathy (r = 0.50, P < .01) but not maximum ankle dorsiflexion, or forefoot deterioration when controlling for neuropathy. These results suggest that the interplay of intrinsic foot muscle deterioration and limited ankle mobility may be the primary contributor to the development of MTPJ deformity. Identifying these muscle and ankle motion impairments as risk factors for MTPJ deformity supports the need for targeted interventions early in the disease process to slow, or possibly stop the progression of deformity over time and reduce the risk of amputation. Level IV, case series.

Diabetic neuropathic forefoot and heel ulcers: management, clinical presentation and outcomes

The two most common sites for diabetic neuropathic foot ulcers are the forefoot and the heel. Each site has special characteristics that determines its course. The aim of this study is to compare clinical presentation, management and outcome of diabetic neuropathic forefoot ulcers to diabetic neuropathic heel ulcers. This was a prospective cross-sectional comparative study carried in Jabir Abu Eliz Diabetic Centre (JADC), Khartoum, Sudan. A hundred patients with neuropathic diabetic ulcer were included, half were forefoot ulcers and the other half were hindfoot ulcers, two patients were lost on follow-up from each group. Neuropathy was graded using 10g monofilament nylon. Patients with vascular ischaemia, ankle brachial index pressure (ABPI) <0.9 and >1.1 were excluded. Other patient's data included demographic, foot and ulcer characteristics, comorbidities and outcomes. Foot ulcers were categorised according to Wagner classification, site and size of ulcer and presence of infection. Comorbidities evaluated included hypertension, ischaemic heart disease and renal impairment. All patients received standard wound care and regular follow-up. The age of the studied patients was 54.3 ± 11 years (mean ± standard deviation (SD 11)) and 52.9 ± 11 years for forefoot and heel ulcer respectively. The mean duration of diabetes was 12.4 ± 6 years for forefoot ulcers and 13.3 ± 7 years for heel ulcer. The mean duration of foot ulcer was 21 and 26 days for forefoot and heel respectively. Forefoot ulcers healed within 12 week in 45% of patients and by 20 weeks in 63%, while 35% of heel ulcers healed by 12 weeks and 54% healed by 20 weeks (p=0.058). Based on Wagner classification, healing was best in class 1 among both forefoot and heel ulcers, 22.4% and 12.2% respectively (p=0.003 for forefoot and 0.002 for heel). First and second metatarsal heads were the common site of forefoot ulcer. Heel ulcers >3cm dimension had longer duration of healing compared to forefoot ulcers at both 12 and 20 weeks (p<0.02). Healing in diabetic neuropathic forefoot ulcer was better than heel ulcer, though not reaching statistically significant value. Wagner class 1 had the best healing among both ulcers and a heel ulcer >3cm had a significantly longer healing time. The authors have no conflict of interest to declare.