Neuroischemic Ulcers Research Articles

A study of association of Diabetic Foot Ulcers and Peripheral Vascular Disease

Background: Diabetic foot ulcers (DFU) are a common, costly, complex, and disabling complication of diabetes resulting in lower-extremity amputations. Diabetes Mellitus (DM) is associated with an increase in the incidence of peripheral vascular disease (PVD) compared to non-diabetic subjects. DFU are divided into two types: neuropathic ulcers (NPU) and neuro-ischemic ulcers (NIU). PVD in association with neuropathy leads to neuro-ischemic ulcers (NIU).Methods: A cross-sectional observational study was conducted for eighteen months period from October 2016 to March 2018, on 120 type-2 DM patients presenting with DFU at tertiary centre in central India. Informed written consent, detailed history was obtained from the patients including duration of diabetes, history of hypertension, smoking, presenting symptoms and other complications related to diabetes. Examination of foot and evaluation for peripheral pulses, ankle brachial pressure index (ABI), neuropathy and blood pressure were done. Laboratory tests for HbA1C, lipid profile, blood urea, serum creatinine and urine albumin creatine ratio (urine ACR) were done. Statistical analysis used: t test, fisher exact test and univariate analysis.Results: In our study, 1594 patients with T2DM were studied, out of which 120 patients presented with new DFU. Mean age of the patients was 61.5years with an M: F ratio of 1.78:1. NIU was present in 36 and NPU in 84 out of 120 DFU patients. Neuro-ischemic ulcers (NIU) were more common among males (28/78 males vs 8/42 females). NIU was found to have significant association with smoking (25/36 patients), hypertension (28/38 patients) and longer duration of diabetes (13.1 vs 9.2years). Other diabetic complications, retinopathy (26/36 patients) and nephropathy (18/36 patients) were more prevalent in patients with NIU. Dyslipidemia was also found in 58.33% (21/36) patients with NIU however the association was insignificant.Conclusions: Diabetic foot ulcers are very debilitating complication of diabetes, and a leading cause of amputations all over the world. Because of increased association of peripheral vascular disease with diabetic foot ulcers there is a rise in prevalence of neuro-ischaemic ulcers. Early management of peripheral vascular disease is important to prevent development of neuro-ischaemic ulcers.

Testing the sympathetic nervous system of the foot has a high predictive value for early amputation in patients with diabetes with a neuroischemic ulcer

ObjectiveThere is evidence from the literature that dysfunctionality of the sympathetic nervous system of the foot with subsequent loss of local autoregulation could be a predictor of early amputation in...

Peripheral arterial disease and neuroischemic ulcers in diabetic Charcot foot: a criminal conspiracy?

Peripheral arterial disease and neuroischemic ulcers in diabetic Charcot foot: a criminal conspiracy?

Frequency of foot ulcers in people with type 2 diabetes, presenting to specialist diabetes clinic at a Tertiary Care Hospital, Lahore, Pakistan

BackgroundDiabetic foot ulceration is a serious limb-threatening complication of diabetes. It is the common cause of hospital admissions and amputations.The objective of the study was to determine the prevalence of diabetic foot ulcers (DFU) and its association with age, gender, duration of diabetes, peripheral neuropathy (PN), peripheral arterial disease (PAD) and HbA1c.MethodsA total of 1940 people (≥ 30 years of age) with type 2 diabetes coming to the Sakina Institute of Diabetes and Endocrine Research (specialist diabetes clinic) at Shalamar Hospital, Lahore, Pakistan, were recruited over a period of 1 year from January 2016 to January 2017. The foot ulcers were identified according to the University of Texas classification. PN was assessed by biothesiometer and PAD by ankle-brachial index (< 0.9). Body weight, height, body mass index (BMI), HbA1c and duration of diabetes were recorded.ResultsThe prevalence of DFU was 7.02%, of which 4.5% of the ulcers were on the planter and 2.6% on the dorsal surface of the foot; 8.5% of the persons had bilateral foot ulcers and 0.4% subjects had Charcot deformity. There was significant association of foot ulcers with age, duration of diabetes, HbA1c, PN and PAD, whereas no association was observed with gender and BMI. PN and PAD were observed in 26.3 and 6.68% of people with diabetes respectively. Neuropathic ulcers and neuro-ischemic ulcers were identified in 74 and 19% of the study population. Logistic regression analysis revealed significant odds ratio for peripheral neuropathy 23.9 (95% confidence interval (5.41–105.6).ConclusionsPeripheral neuropathy is the commonest cause of foot ulcers. An optimum control of blood glucose to prevent neuropathy and regular feet examination of every person with diabetes may go a long way in preventing foot ulceration.

A breakthrough in the management of neuro-ischemic diabetic foot ulcers

A breakthrough in the management of neuro-ischemic diabetic foot ulcers

Sucrose octasulfate dressing versus control dressing in patients with neuroischaemic diabetic foot ulcers (Explorer): an international, multicentre, double-blind, randomised, controlled trial

Diabetic foot ulcers are serious and challenging wounds associated with high risk of infection and lower-limb amputation. Ulcers are deemed neuroischaemic if peripheral neuropathy and peripheral artery disease are both present. No satisfactory treatment for neuroischaemic ulcers currently exists, and no evidence supports one particular dressing. We aimed to assess the effect of a sucrose octasulfate dressing versus a control dressing on wound closure in patients with neuroischaemic diabetic foot ulcers. We did a randomised, double-blind clinical trial (Explorer) in 43 hospitals with specialised diabetic foot clinics in France, Spain, Italy, Germany, and the UK. Eligible participants were inpatients or outpatients aged 18 years or older with diabetes and a non-infected neuroischaemic diabetic foot ulcer greater than 1 cm2 and of grade IC or IIC (as defined by the University of Texas Diabetic Wound Classification system). We excluded patients with a severe illness that might lead to them discontinuing the trial and those who had surgical revascularisation in the month before study entry. We randomly assigned participants (1:1) via a computer-generated randomisation procedure (concealed block size two); stratified by study centre and wound area (1-5 cm2 and 5-30 cm2), to treatment with either a sucrose octasulfate wound dressing or a control dressing (the same dressing without sucrose octasulfate) for 20 weeks. Both groups otherwise received the same standard of care for a 2-week screening period before randomisation and throughout the 20-week trial. Dressings were applied by nursing staff (or by instructed relatives for some outpatients). Frequencies of dressing changes were decided by the investigator on the basis of the clinical condition of the wound. Patients were assessed 2 weeks after randomisation, then monthly until week 20 or occurrence of wound closure. The primary outcome, assessed by intention-to-treat, was proportion of patients with wound closure at week 20. This trial is registered with ClinicalTrials.gov, number NCT01717183. Between March 21, 2013, and March 31, 2016, we randomly assigned 240 individuals to treatment: 126 to the sucrose octasulfate dressing and 114 to the control dressing. After 20 weeks, wound closure occurred in 60 patients (48%) in the sucrose octasulfate dressing group and 34 patients (30%) in the control dressing group (18 percentage points difference, 95% CI 5-30; adjusted odds ratio 2·60, 95% CI 1·43-4·73; p=0·002). In both groups, the most frequent adverse events were infections of the target wound: 33 wound infections in 25 (20%) patients of 126 in the sucrose octasulfate dressing group and 36 in 32 (28%) patients of 114 in the control dressing group. Minor amputations not affecting the wound site were also reported in one (1%) patient in the sucrose octasulfate dressing group and two (2%) patients in the control dressing group. Three (2%) patients assigned to the sucrose octasulfate dressing and four (4%) assigned to the control dressing died, but none of the deaths were related to treatment, procedure, wound progression, or subsequent to amputation. A sucrose octasulfate dressing significantly improved wound closure of neuroischaemic diabetic foot ulcers without affecting safety after 20 weeks of treatment along with standard care. These findings support the use of sucrose octasulfate dressing as a local treatment for neuroischaemic diabetic foot ulcers. Laboratoires Urgo Medical.

Complicaciones asociadas a la terapia de presión negativa en el tratamiento de las úlceras de pie diabético

We performed a retrospective study on 68 diabetic patients with foot ulcer treated in Diabetic Foot Unit of Complutense University of Madrid with Negative Pressure Therapy (NPT). The aim of this study is evaluate the possible complications from the use of this therapy. After apply the inclusion and exclusion criteria we obtained a sample of 57 patients. The most common complications observed were haemorrhage, pain, perilesional maceration, necrosis and infection of the ulcer. The most common complication and most easily solvable was perilesional maceration (49.2%). We conclude that negative pressure therapy promotes granulation tissue neoformation and is an efficient and effective therapy for the treatment of neurophatic, ischemic and neuroischemic diabetic foot ulcers.

Bacterial Profile and Antibiotic Resistance in Patients with Diabetic Foot Ulcer in Guangzhou, Southern China: Focus on the Differences among Different Wagner's Grades, IDSA/IWGDF Grades, and Ulcer Types.

Objective To understand the bacterial profile and antibiotic resistance patterns in diabetic foot infection (DFI) in different Wagner's grades, IDSA/IWGDF grades, and different ulcer types in Guangzhou, in order to provide more detailed suggestion to the clinician about the empirical antibiotic choice. Methods 207 bacteria were collected from 117 DFIs in Sun Yat-sen Memorial Hospital from Jan.1, 2010, to Dec.31, 2015. The clinical data and microbial information were analyzed. Results The proportion of Gram-negative bacteria (GNB) was higher than Gram-positive bacteria (GPB) (54.1% versus 45.9%), in which Enterobacteriaceae (73.2%) and Staphylococcus (65.2%) were predominant, respectively. With an increasing of Wagner's grades and IDSA/IWGDF grades, the proportion of GNB bacterial infection, especially Pseudomonas, was increased. Neuro-ischemic ulcer (N-IFU) was more susceptible to GNB infection. Furthermore, with the aggravation of the wound and infection, the antibiotic resistance rates were obviously increased. GPB isolated in ischemic foot ulcer (IFU) showed more resistance than the N-IFU, while GNB isolates were on the opposite. Conclusions Different bacterial profiles and antibiotic sensitivity were found in different DFU grades and types. Clinician should try to stay updated in antibiotic resistance pattern of common pathogens in their area. This paper provided them the detailed information in this region.

Characterization of patients with diabetic foot disease presenting to an Irish Podiatry Centre: profiling suitability for entry to a clinical trial of advanced wound therapeutics.

Diabetes mellitus, coined the 'Black Death of the Twenty-First Century', is associated with complications, including foot ulceration with potential loss of limb. There is a need for development of new wound therapies through completion of robust clinical trials. To profile demographics and wound characteristics of an Irish cohort with diabetes, forecast eligibility for entry to a clinical trial of advanced wound therapeutics, and adjust criteria to optimize eligibility for enrolment. A cross-sectional study of out-patients attending a Podiatry centre over 12weeks was conducted. Information was collected through clinical assessment, including Neuropathy Disability Score and Ankle-Brachial Pressure Index. Ulcers were characterised as 'healing' or 'non-healing'; a 'healing' wound decreased by 30% over the previous month, accomplished by retrospective analysis of files. Statistics, including binomial logistic regression and column analysis for eligibility assessment, were conducted. Seventy-four participants were identified with a mean age of 67 (±8.79) years. Non-healing DFU status correlated significantly with larger wound area (P=0.013), infection (P=0.009), and greater degrees of ischaemia (P=0.015). The eligibility criteria were modelled after those proposed by the EU consortium project REDDSTAR. In this Irish population, these criteria limit eligibility to 1.4%. This research found an eligibility criterion of wound area 2-10cm2 for enrolment in a clinical trial of mesenchymal stromal cell therapy too restrictive. Extension of wound area to 1-10cm2 and the inclusion of neuro-ischaemic ulcers increased eligibility for enrolment from 1.4 to 20%.

P10 Investigating the wound healing capacity of outgrowth endothelial cells from diabetic neuropathy and neuroischaemia patients

Endothelial dysfunction and inflammation are the most important parameters in the pathogenesis of diabetes, and these processes underpin the development of diabetic foot ulcers. Outgrowth endothelial cells (OECs) have therapeutic potential for diabetic wounds because of their ability to proliferate, migrate and promote angiogenesis. However, the precise mechanisms supporting their differentiation capacity, physiological roles and homing to sites of injury remain to be elucidated. This study aims to establish the function of OECs from diabetic patients with neuroischaemic and neuropathic ulcers, and determine their potential role in wound healing. Healthy volunteer subjects provide OECs as comparative control cells. Migration of CD34+ OECs, evaluated by a scratch assay, demonstrated that migration is impaired in neuropathic OECs compared to healthy control and neuroischaemic OECs. An angiogenesis tube formation assay also established a lack of capacity and reduced capacity of the neuropathic and neuroischaemic OECs respectively to form an endothelial network, compared to healthy OECs measured using the closed loop perimeter, and the number of branch points. Nitrite concentrations measured using a Griess assay, showed that diabetic OECs produced less nitric oxide as compared to healthy OECs. Cytokine analysis of patient serum and OEC supernatant using Bioplex suspension array technology has also been carried out, to determine any correlation between OEC function, the inflammatory and angiogenic profile of the patient. These data are under analysis and will be presented. Understanding these parameters could have great clinical impact in the development of novel wound healing therapies among diabetic patients to reduce ongoing complications.

DIABETIC FOOT ULCER

Objectives: To determine the risk factors contributing to the development ofdiabetic foot ulcers. Study Design: A descriptive observational study. Setting: Unit of surgery,City Hospital Lakki Marwat, Khyber Pakhtunkhwa. Period: 1st July 2013 to 30th June 2015.Patients and Material: One hundred and fifty diabetic patients with foot ulcer were studied.After taking informed consent, detailed history, clinical examination and relevant investigationswere performed according to a devised proforma. All the proformas were analyzed in the endof study. Results: One hundred and fifty patients comprising 95 male and 55 female werestudied. The average diabetic duration was 11 years. HbA1c was more than 8% in 98 (65.3%)patients. Peripheral neuropathy was present in 60 patients (40%), peripheral vascular diseasein 80 patients (53.3%), neuro-ischemic ulcers in 45 patients (30%), hypertension in 70 patients(46.6%), Ischemic heart disease in 20%, Dyslipidemia in 50%, foot deformity in 42% andaccidental/ foot wear trauma in 44%. Conclusion: Foot ulcer in diabetes results from multiplepathophysiologic mechanisms. Implementation of strategies for prevention, early detection,and appropriate treatment at the primary health care level are urgently needed.

Multidisciplinary team approach for diabetic foot patients in an out-patient clinic

To assess the effectiveness of multidisciplinary team approach in daily practice of diabetic foot. 376 diabetic patients (446 ulcers) treated in a diabetic foot department in 2014 were examined. All patients were screened for diabetic peripheral polyneuropathy and blood insufficiency of lower extremities in order to diagnose the type of diabetic foot ulcer: neuropathic or neuroischemic. Patients were treated by a multidisciplinary team. The number of healed ulcers, minor and major amputations was analyzed. 80% of diabetic foot ulcers were neuropathic with normal blood supply, 20% had signs of ischemia. 77.8% of the ulcers healed in the general group during the study period. 13 amputations (2.9%) were done in the study group: 7 minor amputations (1.6%), 2 below the knee (0.4%), and 4 above knee (0.9%). Two patients died from cardiovascular events (0.4%). The comparative analysis of outcomes of neuropathic and neuroischemic ulcers showed that 84% of neuropathic ulcers healed. Minor amputations were done in 1% of the cases, no major amputations were performed. In patients with neuroischemic ulcers, 60% of them healed, minor amputations were made in 3.4% of cases (2.3% below knee, 4.6% above knee). The majority of diabetic ulcers in the study group were neuropathic with normal blood supply. The main risk factor of major amputations is ischemia of the affected limb. The multidisciplinary team approach in daily practice of the diabetic foot department of an out-patient clinic is instrumental in healing ulcers and minimizing the risk of major amputations.

The Diabetic Foot: The Never-Ending Challenge.

Diabetes, a major public health concern, is increasing in prevalence worldwide. A diabetic patient has an up to 25% lifetime risk of developing a foot ulcer condition that predisposes that patient to lower-extremity amputation. The underlying pathology is diabetic peripheral neuropathy and peripheral arterial disease (PAD) associated with deformities of foot anatomy due to motor neuropathy. Trauma, often secondary to ill-fitting shoes, precipitates skin breakdown, whereas PAD determines the prognosis for healing. Whenever optimal offloading is guaranteed, a neuropathic ulcer will heal, whereas an ulceration compromised by even a minor degree of arterial insufficiency has little chance of healing without revascularization. The population presenting with diabetic foot ulcers has shown a clear shift from neuropathic ulcers to neuro-ischaemic ulcers over the last two decades, underscoring the necessity to adapt management strategies to this condition. Cohort studies (the Eurodiale study group) teach us that the underlying problems are an absence of assessment of PAD, underuse of imaging and late referral for revascularization. Regarding reducing amputation rates in diabetes, a highly preventable complication, the situation is far from being under control. Prevention strategies targeting the high-risk population to avoid ulcer recurrence, optimized management by multidisciplinary foot care teams, integrated care with a clear definition of the patient itinerary and anticipated action to ameliorate ischaemia are promising options for the future.

Clinical approach to the neuroischemic ulcers in diabetic foot

Neuroischemic diabetic foot ulcer (NDFU) is characterized by infection, ulceration of deep tissues, neurological abnormalities, and various degrees of peripheral vascular disease in the lower limbs. The patients often have multiple risk factors such as older, longer duration, cardiovascular disease. The treatment is very difficult. The prognosis depends on the severity of complications, tissue range of infections, and the peripheral vascular disease. In this article, the treatment process of an old inpatient with NDFU and severe complications was reviewed and to propose a standard pathway for its management. Key words: Neuroischemic; Diabetic foot; Foot ulcers

Epidemiology of type 2 diabetic foot problems and predictive factors for amputation in China.

To determine incidence and clinically relevant risk factors for diabetic amputation in a large cohort study of diabetic foot ulceration patients in China, we investigated a total of 669 diabetic foot ulceration patients, who were assessed at baseline for demographic information, medical and social history, peripheral neuropathy screening, periphery artery disease screening, assessment of nutritional status and diabetic control, physical examination including foot deformity in 15 Grade III-A hospitals. Of the 669 patients, 435 were male and 201 were female, with the mean age being 64.0 years. Of all patients, 110 had neuropathic ulcers, 122 had ischemic ulcers, 276 had neuroischemic ulcers, and 12 cases were unclassified. Wagner classification showed 61 cases were grade I, 216 cases grade II, 159 cases grade III, 137 cases grade IV, and 7 cases grade V. The overall amputation rate among diabetic foot patients was 19.03%, and major and minor amputation rates were 2.14% and 16.88%, respectively. By univariate analysis, statistically significant differences were found in smoking, rest pain, ulcer history, revascularization history, amputation history, gangrene, infection, Wagner grades, duration of diabetes, and postprandial blood glucose, aldehyde, total protein, globulin, albumin, white blood cell (WBC), hemoglobin, HbA1c, ulcer property, body mass index, as well as creatinine. Binary logistic regression model showed that increased WBC (odds ratio 1.25) and ulcer history (odds ratio 6.8) were associated with increased risks from diabetic foot ulcer to major amputation; increased duration of diabetes (odds ratio 1.004), WBC (odds ratio 1.102), infection (odds ratio 2.323), foot deformity (odds ratio 1.973), revascularization history (odds ratio 2.662), and decreased postprandial blood sugar (odds ratio 0.94) were associated with increased risks from diabetic foot ulcer to minor amputation. It is of great importance to give better management to diabetic patients at early stages. Following a diagnosis of DFU more intensive surveillance and aggressive care may improve outcome.

Comparison of characteristics and healing course of diabetic foot ulcers by etiological classification: Neuropathic, ischemic, and neuro-ischemic type

AimsTo identify differences in the characteristics of patients with diabetic foot ulcers (DFUs) according to their etiological classification and to compare their healing time. MethodsOver a 4.5-year period, 73 patients with DFUs were recruited. DFUs were etiologically classified as being of neuropathic, ischemic, or neuro-ischemic origin. Descriptive analyses were performed to characterize study subjects, foot-related factors, and healing outcome and time. Duration of healing was assessed using the Kaplan–Meier method. Healing time among the three types was compared using the log rank test. ResultsThe number of patients manifesting neuropathic, ischemic, and neuro-ischemic ulcers was 30, 20, and 14, respectively. Differences were identified for age, diabetes duration, body mass index, hypertension, and estimated glomerular filtration rate. Patients with neuro-ischemic ulcers had better ankle–brachial index, skin perfusion pressure (SPP), and transcutaneous oxygen pressure values compared to those with ischemic ulcers. The average time in which 50% of patients had healed wounds was 70, 113, and 233days for neuropathic, neuro-ischemic, and ischemic ulcers, respectively. Main factors associated with healing were age and SPP values. ConclusionsBased on the etiological ulcer type, DFU healing course and several patient factors differed. Failure to consider the differences in DFU etiology may have led to heterogeneity of results in previous studies on DFUs.

Comorbidities associated with Egyptian diabetic foot disease subtypes

Abstract Introduction Diabetic foot problems are highly prevalent, responsible for almost 50% of all diabetes-related hospital admissions and a 10-year reduction in life expectancy. The main factors involved in the pathology of diabetic foot are neuropathy, ischemia, and infection. The comorbidities of diabetes are hypertension, obesity, and dyslipidemia. Because of the huge premature morbidity and mortality associated with diabetes, prevention of complications is a key issue and, therefore, it is essential to understand the basic mechanisms that lead to tissue damage. Aim of the work The aim of our study was to detect the association between patient comorbidities, chronic complications, and different diabetic foot types for the early detection and management of these conditions. Patients We carried out a cross-sectional study of 80 consecutive outpatient Egyptian patients with diabetic foot disease in the National Institute of Diabetes and Endocrinology. Results Sixty-three percent were purely neuropathic, followed by 19% that were neuroischemic, whereas 18% were of the ischemic type. Hypertension is the most common comorbid condition and coronary artery disease is highly prevalent in the ischemic and neuroischemic types. The coexistence of hypercholesterolemia, smoking, diabetes, and male sex appears to significantly increase the incidence of ischemic diabetic foot. Nephropathy and retinopathy are significantly associated with neuropathic foot ulcers. Hypertriglyceridemia correlates positively to ischemic and neuroischemic ulcers whereas low HDL and proteinuria correlate positively to both neuropathic and neuroischemic ulcers. Conclusion Special attention should be paid toward the identification of patients who are at risk of foot ulceration to help prevent foot problems. Comorbid conditions must also be identified early and managed aggressively.

Reconsidering Nerve Decompression: An Overlooked Opportunity to Limit Diabetic Foot Ulcer Recurrence and Amputation

Nerve decompression for relief of subjective diabetic sensorimotor polyneuropathy pain and numbness has been labeled of "unknown" benefit. Objective outcomes in treatment and prevention of diabetic foot complications are reviewed. There is growing evidence that plantar foot ulceration and recurrence in high-risk feet are minimized with this operation. Avoiding neuropathic and neuroischemic ulcer wounds should theoretically reduce amputations and perhaps mortality risk. Protective effects are hypothesized to act via relief of neuro-vascular entrapment, thereby improving neurally modulated tissue homeostasis factors. Nerve decompression deserves considerable research attention to understand its role in limiting foot complications. Its apparent benefits challenge the paradigm that diabetic neuropathy is a purely length-dependent axonopathy and may necessitate appreciation of superimposed nerve entrapment as an significant operant factor.

Percutaneous flexor tenotomy for preventing and treating toe ulcers in people with diabetes mellitus

IntroductionThe purpose was to examine the effectiveness of flexor tenotomy in a modified technique to prevent and heal neuropathic and neuroischaemic pressure ulcers on the tip of the toe in claw- or hammer-toe deformities in people with diabetes. Patients and methodsA consequetive 4 years series of 38 patients was retrospectively studied. Percutaneous tenotomy on the superficial and deep flexor tendons was performed in 65 toes through a small transverse plantar stab incision just proximal to the web level. There were 16 (42%) patients with 27 ulcerated toes and 22 (58%) patients with 38 toes with impending ulceration. Ten patients had neuropathic ulcers and six patients had neuro-ischaemic ulcers. Sixteen patients (42%) had macrovascular disease. Ten (26%) had proliferative rethinopathy, 7 (18%) macroalbuminuria and 18 (47%) microalbuminuria. ResultsAll surgical incisions healed uneventfully. Twenty-five (93%) of the toe ulcers healed in median 21 days (range 7–224 days). Three patients had recurrence of the ulcer. There were no infections in the incisions or toe amputations. No patients treated with preventive tenotomy experienced toe ulceration. No complications were recorded in neuro-ischaemic ulcers. During the follow up period of median 31 months (range 2–48 months) 33 other ulcers were recorded in 18 patients (47%). One of these developed a transfer ulceration under the adjacent metatarso-phalangeal joint and another had a late pressure ulcer on a neighbouring toe. The other 31 ulcers were not related to ulcers treated with tenotomy. ConclusionTenotomy is a simple, safe and effective procedure for preventing and treating distal plantar neuropathic toe ulcers in claw toe or hammer toe deformities in people with diabetes with or without serious co-morbidity. The results suggest that tenotomy should be considered also in neuroischaemic ulcers.

Prevention of diabetic foot ulceration: new evidences for an old problem

Diabetic patients have a 15 % lifetime risk of developing a foot ulcer and have a 15 % risk of developing a lower extremity amputation. Amputation is preceded by nonhealing foot wounds in 85 % of cases [1]. The ulcerated diabetic foot may be considered the complication of the peripheral neuropathy (PN) and/or peripheral arterial disease (PAD). Several studies showed that diabetic patients with PN are at risk of foot ulceration and indeed true neuropathic ulceration is found in almost 50 % of the patients with a new foot ulcer according to eurodiale [2]. Those with PAD are at risk of foot amputation and ischemic lesions are found in the other 50 % of patients with foot ulceration. However true ischemic ulcers are observed only in 15 % of cases. The remaining 35 % have both PAD and PN present at the same time: neuroischemic ulcers [2]. Many factors may be responsible of the appearance of an ulcer in those patients: intrinsic factors related to the progressive appearance of limited joint mobility, soft tissue stiffness, early and persistent windlass mechanism [3] presence of structural foot deformities as hammer toes, hallux valgus or pes cavus. Metatarsal heads are prominent. This results in increased pressure underneath the metatarsal heads, which will make the plantar forefoot more susceptible to breakdown, also because patients are unaware of this abnormal pressure because of the neuropathy. However, there are also other contributing factors leading to diabetic foot ulcer formation, such as arterial occlusive disease, foot trauma, history of previous amputations, and callus due to the increased plantar pressures caused by abnormal mechanical loading of the foot [4]. A sequence of