Neuropathic Ulcers Research Articles

Long term outcomes after incident diabetic foot ulcer: Multicenter large cohort prospective study (EDI-FOCUS investigators) epidemiology of diabetic foot complications study: Epidemiology of diabetic foot complications study

AimsThis long-term prospective study evaluated limb amputation and mortality after the first neuropathic diabetic foot ulcer (DFU). MethodsA total of 2880 patients with neuropathic DFU (DFU group) and a similar number of patients of diabetes without DFU (nDFU) matched for age and diabetes duration were prospectively assessed at five referral-centers over 14 years. Pre-defined outcome was death during follow-up. Various diabetic co-morbidities and amputation were assessed as mortality predictors. ResultsOverall, 501 (17.4%) patients in DFU group died compared to 89 (3.1%) (p < 0.01) in nDFU group during a median follow-up of 7(1–14) years. The 5- and 10-year mortality was 22% and 71% in the DFU group with a median survival of 7.72 (7.37–8.08) years compared to 3% (p < 0.01) and 5% (p < 0.01) and survival of 12.6 (10.5–12.7) years (p < 0.001) in nDFU group. 29.3% patients had limb amputations. The mortality risk was independent of glycemic control [OR 1.03 (0.80–1.32; p = 0.83)]. However, diabetes duration > 10 years [OR 1.31(1.02–1.70, p = 0.035)], nephropathy [OR 1.47 (1.04–2.09, p < 0.030)], minor 1.85 (1.40–2.44; p < 0.001) or major amputation 2.96 (2.01–4.34, p < 0.001)] predicted mortality. ConclusionsEvery one-in-three individual with neuropathic DFU has amputation and every sixth individual has an early demise. Prevalent nephropathy and incident amputation following DFU predicts mortality.

Application of a collagen matrix dressing on a neuropathic diabetic foot ulcer: a randomised control trial.

Diabetic foot ulcers (DFU) are often hard-to-heal, despite standard care. With such a complicated healing process, any advanced wound care to aid healing is recommended. Chitosan/collagen composite hydrogel materials have the potential to promote the regenerative process. In this study, the efficacy of a new collagen matrix dressing including chitosan/collagen hydrogel was compared with a standard dressing of saline-moistened gauze for wound healing in patients with a hard-to-heal neuropathic DFU. This is an open labelled, randomised clinical trial. After conventional therapy consisting of debridement, infection control and offloading, patients were randomly allocated to receive either a collagen matrix dressing (the study group, receiving Tebaderm manufacturer) or a saline-moistened gauze dressing (control group) for wound care. The reduction in DFU size and the number of patients with complete healing were measured throughout the treatment and in follow-up. A total of 61 patients with a neuropathic DFU were recruited. Average percentage reduction in DFU size at four weeks was greater in the study group compared with the control group (54.5% versus 38.8%, respectively). Rate of complete healing rate at 20-weeks' follow-up was significantly better in the study group than the control group (60% versus 35.5%, respectively). The collagen matrix dressing used in this study accelerated the healing process of patients with a hard-to-heal DFU. Further research may suggest the used of this dressing to shorten the length of time to achieve complete healing.

Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review.

Offloading interventions are commonly used in clinical practice to heal foot ulcers. The aim of this updated systematic review is to investigate the effectiveness of offloading interventions to heal diabetic foot ulcers. We updated our previous systematic review search of PubMed, EMBASE, and Cochrane databases to also include original studies published between July 29, 2014 and August 13, 2018 relating to four offloading intervention categories in populations with diabetic foot ulcers: (a) offloading devices, (b) footwear, (c) other offloading techniques, and (d) surgical offloading techniques. Outcomes included ulcer healing, plantar pressure, ambulatory activity, adherence, adverse events, patient-reported measures, and cost-effectiveness. Included controlled studies were assessed for methodological quality and had key data extracted into evidence and risk of bias tables. Included non-controlled studies were summarised on a narrative basis. We identified 41 studies from our updated search for a total of 165 included studies. Six included studies were meta-analyses, 26 randomised controlled trials (RCTs), 13 other controlled studies, and 120 non-controlled studies. Five meta-analyses and 12 RCTs provided high-quality evidence for non-removable knee-high offloading devices being more effective than removable offloading devices and therapeutic footwear for healing plantar forefoot and midfoot ulcers. Total contact casts (TCCs) and non-removable knee-high walkers were shown to be equally effective. Moderate-quality evidence exists for removable knee-high and ankle-high offloading devices being equally effective in healing, but knee-high devices have a larger effect on reducing plantar pressure and ambulatory activity. Low-quality evidence exists for the use of felted foam and surgical offloading to promote healing of plantar forefoot and midfoot ulcers. Very limited evidence exists for the efficacy of any offloading intervention for healing plantar heel ulcers, non-plantar ulcers, and neuropathic ulcers with infection or ischemia. Strong evidence supports the use of non-removable knee-high offloading devices (either TCC or non-removable walker) as the first-choice offloading intervention for healing plantar neuropathic forefoot and midfoot ulcers. Removable offloading devices, either knee-high or ankle-high, are preferred as second choice over other offloading interventions. The evidence bases to support any other offloading intervention is still weak and more high-quality controlled studies are needed in these areas.

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.

MRI and Technetium-99m Hexamethylpropylene Amine Oxime Labeled Leucocyte Scintigraphy in the Diagnosis and Differentiation between Acute Osteomyelitis and Neuroarthropathy in the Diabetic Foot

Abstract Background: Soft tissue and bone infection and neuro osteoarthropathy involving the foot are the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Both pathologies often coexist and differentiating between them is crucial because the management may differ substantially. Misdiagnosis may result in high morbidity for the patient such as unnecessary limb amputation. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglu-cose-positron emission tomography and nuclear imaging studies. Aim of Study: The aim of this study is to evaluate the diagnostic value of MRI and technetium-99m Hexamethyl-propylene Amine Oxime (HMPAO) labeled leukocyte scin-tigraphy in the diagnosis and differentiation between acute osteomyelitis and neuroarthropathy in the diabetic foot. Patients and Methods: The study included 35 patients (20 men and 15 women) aged 62±8.8 years having diabetes mellitus and a total of 43 clinically suspicious infection sites. The basic exploration included standard radiography, three-phase bone scintigraphy and 99mTc-HMPAO Leucocyte Scan (HMPAO-LS) and pre and post contrast enhanced MRI. 16 bone and 10 soft tissue biopsies were obtained from ulceration sites. Clinical follow-up as well as scintigraphy and MRI performed 4 months after initial diagnosis and 1 month after antibiotic withdrawal were performed in suspected osteomy-elitis cases. Results: Among the 43 sites, 23 sites were finally diag-nosed as osteomyelitis. No osteomyelitis was present at 20 sites, of which 9 sites were diagnosed as cellulitis and 11 as neuropathic ulcers based on combined clinical, imaging, pathologic findings and follow-up. The sensitivity and specif-icity of MRI were (95% and 85%) and of Labeled leucocyte scanning were (87% and 90%) respectively.Conclusion: The combined use of 99mTc-HMPAO-LS and MRI yielded higher diagnostic efficacy in diabetic foot related complications.

Comparison of two pixelated insoles using in-shoe pressure sensors to determine percent offloading: case studies.

The gold standard for offloading neuropathic forefoot and midfoot wounds is the total contact cast (TCC). However, in practice TCC is rarely used and is contraindicated in patients with fluctuating oedema, poor perfusion, lack of adequate tissue oxygenation and morbid obesity. It can also be too restrictive for patients, inevitably resulting in treatment rejection and delayed healing. This paper examines the role of shoe-based offloading devices as an alternative in reducing plantar pressure and optimising the healing of neuropathic ulcers. Healthy subjects were recruited and fitted for two types of pixelated insoles: PegAssist (PA) insole system (Darco International, US) and FORS-15 (FORS) offloading insole (Saluber, Italy). An area of discreet, elevated high pressure was created by adding a 1/4-inch-thick felt pad to the plantar skin under the first metatarsal head. Subjects walked barefoot in surgical shoes with standard insoles (Condition 1), barefoot in pixelated insoles (Condition 2), barefoot with pixels removed (Condition 3). Dynamic plantar pressures were measured using F-Scan and the results were analysed to determine plantar pressure changes in each condition. Using PA, the percentage reduction of plantar pressure (kPa) under the first metatarsal between Condition 1 and Condition 2 was 10.54±15.81% (p=0.022), between Condition 2 and Condition 3 was 40.13±11.11% (p<0.001), and between Condition 1 and Condition 3 was 46.67±12.95 % (p<0.001). Using FORS, the percentage reduction between Condition 1 and Condition 2 was 24.25±23.33% (p=0.0029), between Condition 2 and Condition 3 was 23.61±19.45% (p<0.001), and between Condition 1 and Condition 3 was 43.39±18.70% (p<0.001). A notable difference in the findings between the two insoles was the presence of a significant edge effect associated with PA, indicating that the offloading was not entirely successful. No edge effect was detected with FORS. Our current analysis shows that pixelated insoles exhibit potential for supplemental offloading in surgical shoes. These devices could provide an alternative way for physicians to offload plantar wounds and expedite closure for patients that cannot tolerate a TCC or other restrictive devices.

A prospective study to determine the application of site, ischemia, neuropathy, bacterial infection and depth scoring in the outcome and management of diabetic foot ulcers

Background: The objective of the study was to classify diabetic ulcers based on the recently described SINBAD classification system and to determine the management based on SINBAD score.Methods: Prospective study, conducted in Victoria Hospital from November 2017 to May 2019. 120 patients with diabetic ulcers were classified according to the SINBAD classification system, wherein a score of one is given for site beyond forefoot, presence of ischemia, presence of neuropathy, bacterial infection, area &gt;1 cm2 and depth beyond subcutaneous tissue. The wounds are scored at presentation and the outcome are evaluated according to respective score.Results: In this study 120 patients with mean age of 50.12 years were included. Lower socio-economic groups correlated with higher incidence of diabetic foot. According to SINBAD classification 42.5% had forefoot, 57.5% had hind foot wounds, 56.3% were purely ischemic ulcers, 19.2% were neuropathic ulcers, 40.0% were neuro-ischemic ulcers 68.3% had bacterial infection, 70.8% had ulcer, size &gt;1 cm2, 55% had ulcer deeper than skin &amp; sub cutaneous tissues. Healing probability in score 1 was 100%, score 2 was 87.5%, Score 3 was 70%, score 4 was 58.6% healing, score 5 was 7.1% and score 6 was 1.1% healing (p=0.004). Ischemia, neuropathy, bacterial infection, area &gt;1 cm2 and depth beyond subcutaneous tissue had significant effect on healing.Conclusions: SINBAD classification system includes 6 parameters, describing the pathological evolution of diabetic ulcers. Treatment protocols can be determined based on the score. The system is easy to score and apply in routine practise.

Egyptian consensus for the use of antimicrobial therapy in Preoperative prophylaxis, surgical site infections and diabetic foot infections

Use of antimicrobials in surgical prophylaxis These consensuses focus on primary perioperative prophylaxis for the prevention of an initial infection, the administration of the first dose of antimicrobial beginning within 60 min before surgical incision is recommended, but administration of vancomycin and fluoroquinolones should begin within 120 min before surgical incision because of the prolonged infusion times required for these drugs. Dosing In general, it is advisable to administer prophylactic agents in a manner that will ensure adequate levels of drug in serum and tissue for the interval during which the surgical site is open, If the duration of the procedure exceeds two half-lives of the antimicrobial or there is excessive blood loss (>1500 ml), the re-dosing interval should be measured from the time of administration of the preoperative dose, not from the beginning of the procedure. The selection of certain antimicrobial in most of the surgeries is shown in Table 2, and the special dosing of antimicrobials in patients with renal impairment is shown in Table 3. Surgical site infections “SSI” SSIs or wound infections are the most common adverse events affecting hospitalized surgical patients. The most important therapy for an SSI is to open the incision, evacuate the infected material, and continue dressing changes until the wound heals by secondary intention. Before starting an empiric antibiotics course, culture should be done. The antibiotic choice is usually empiric but can be supported by Gram stain, culture of the wound contents, the site of surgery, and the hospital antimicrobial susceptibility test system ‘Hospital Biogram’. The selection of Antibiotics for treatment of incisional surgical site infections is summarized in table 4. Diabetic foot infections Diabetic Foot infections typically begin in a wound, most often a neuropathic ulceration, while all wounds are colonized with microorganisms, and the presence of infection is defined by greater than or equal to 2 classic findings of inflammation or purulence. Most DFIs are polymicrobial, with aerobic gram-positive cocci, and especially Staphylococci spp., the most common causative organisms. Clinicians should consider the possibility of infection occurring in any foot wound in a patient with diabetes. Clinicians should evaluate a diabetic patient presenting with a foot wound at three levels: the patient as a whole, the affected foot or limb, and the infected wound. The clinically noninfected wounds should not be treated with antibiotic therapy. Prescription of antibiotic therapy for all infected wounds should be done, but with caution, as it is often insufficient unless combined with appropriate wound debridement. The clinicians need to select an empiric antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (shown in Table 6).

Diabetic Polyneuropathy - Advances in Diagnosis and Intervention Strategies.

Over half of people with diabetes mellitus develop diabetic polyneuropathy (DPN), which is a major cause of reduced quality of life due to disabling neuropathic pain, sensory loss, gait instability, fall-related injury, and foot ulceration and amputation. The latter represents a major health and economic burden, with lower limb amputation rates related to diabetes increasing in the UK. There is a need for early diagnosis of DPN so that early management strategies may be instigated, such as achieving tight glucose control and management of cardiovascular risk factors, in an attempt to slow its progression. To this end, a one-stop microvascular assessment involving a combined eye, foot and renal screening clinic has proven feasible in the UK. Unfortunately, there are currently no approved disease-modifying therapies for DPN. Some disease-modifying agents have demonstrated efficacy, but further large trials using appropriate clinical endpoints are required before these treatments can be routinely recommended. There has been emerging evidence highlighting a reduction in vitamin D levels in cases of painful DPN and the potential for vitamin D supplementation in deficient individuals to improve neuropathic pain; however, this needs to be proved in randomised clinical trials. The use of established agents for neuropathic pain in DPN is limited by poor efficacy and adverse effects, but patient stratification using methods such as pain phenotyping are being tested to determine whether this improves the outcomes of such agents in clinical studies. In addition, innovative approaches such as the topical 8% capsaicin patch, new methods of electrical stimulation and novel therapeutic targets such as NaV1.7 offer promise for the future. This article aims to discuss the challenges of diagnosing and managing DPN and to review current and emerging lifestyle interventions and therapeutic options.

The Efficiency of Bioapifit® Wound Care Ointment in the Treatment of Diabetic Foot Ulcers

Objective/Purpose: The objective of this study was efficacy and safety assessment of Bioapifit® wound care ointment consisted of honey, Cera flava, glycerin, the oil macerates of astringent and soothing herbs combined with essential oils for the treatment of diabetic neuropathic foot ulcers of grade II. Materials and methods: 50 patients with Wagner grade II diabetic foot ulcers were randomized into experimental and control group (25 patients each). The experimental group was treated 28 days with Bioapifit® wound care ointment applied on the wound after cleaning with povidone iodine once a day and covered with sterile gauze and bandage during the whole course of the study. The control group wounds were cleaned with povidone iodine once a day and covered with sterile gauze and bandage during the whole course of the study without further treatment. The ulcers surface area was measured at baseline and after 14 and 28 days of the treatment. Results: In the end of the treatment the mean values and standard deviation of the surface area in the experimental group dropped from 8.27±6.1 cm 2 to 0.74±0.21 cm 2 for males and from 9.01±5.9 cm 2 to 0.81±0.11 cm 2 for females. Slight, insignificant decrease was also observed in the control population (up to 25%). No side-effects were observed during the course of the study. Conclusion/Discussion: Four weeks treatment with Bioapifit® wound care ointment resulted in complete wound closure in 84% of the patients and 91% reduction in the wound surface area in the rest of them.

Mobility advice to help prevent re-ulceration in diabetes.

Clinicians and patients face a dilemma in understanding how best to resume walking after a healed diabetic neuropathic ulcer. The objectives of this brief review are to: provide context for the patient's health and mobility status; propose 5 suggestions to safely and effectively progress mobility following a healed foot ulcer; and to consider topics for future research to improve care in this area. Rates of ulcer recurrence and mortality are high, and activity is low following a diabetic foot wound. Medical and rehabilitation approaches have emphasized protection of the insensitive, fragile foot with the hope to prevent subsequent harm to the foot and person. In particular, the 1-2 months following wound unloading and "healing" have the greatest risk for ulcer recurrence. While early protection should be emphasized, a growing body of evidence suggests that over-protection of the foot and limited walking can be harmful, presumably because of the negative effects of prolonged immobility and stress protection. Multiple recent studies report the ability of exercise and walking to have a positive effect on various diabetic foot outcomes without additional harm. Much less is known about how an ulcerated foot can resume walking after the wound is healed. This review integrates available guidelines, evidence, and precautions to suggest advice on how best to resume and progress walking in this population at high risk for ulcer recurrence.

Negative-Pressure Wound Therapy in Foot and Ankle Surgery.

Negative Pressure Wound Therapy (NPWT) is frequently utilized to manage complex wounds, however its mechanisms of healing remain poorly understood. Changes in growth factor expression, micro- and macro-deformation, blood flow, exudate removal, and bacterial concentration within the wound bed are thought to play a role. NPWT is gaining widespread usage in foot and ankle surgery, including the management of traumatic wounds; diabetic and neuropathic ulcers; wounds left open after debridement for infection or dehiscence; high-risk, closed incisions; tissue grafts and free flaps. This article reviews the rationale for NPWT, its proposed mechanisms of action, and the evidence regarding its clinical applications within the field of foot and ankle surgery. Level of Evidence: Level V, expert opinion.

Healing of wounds in lower extremities employing a non-thermal plasma

Purpose: Venous, neuropathic, and mixed (venous and arterial) ulcers are complex chronic wounds that have a tremendous long-term impact on the mortality, morbidity, and quality of life of patients. In this work it was evaluated the efficacy of the non-thermal helium plasma at atmospheric pressure applied in patients with this suffering.Methods: Using three elements: a RF generator, a needle-type reactor, and helium gas flow, for non-thermal plasma generation were used. The power density on the tissue of patients was of 0.6–0.67 W/cm2. The application time was 30 s/cm2 daily, at 5 to 10 mm of distance from the wound.Results: The thirty-two patients with venous and mixed ulcers indicated that they had a decrease progressively of the pain with the therapy, without the need to continue with analgesics. Besides, the ten patients with chronic wounds showed 100% healing in neuropathic ulcers. For eight patients with venous leg ulcers, the percentage was reduced to 75% healing. While for fourteen patients with mixed leg ulcers, the rate of healing was 59%.Conclusion: The non-thermal plasma generated in a needle reactor with helium gas is a promising candidate for clinical and therapeutic use in the treatment of neuropathic leg ulcers, with time reduction healing, and it can be applied everyday. In the study conducted, it was found that the non-thermal plasma applied to patients with autoimmune diseases clinically was not beneficial.

Surgical Offloading Techniques Should be Used More Often and Earlier in Treating Forefoot Diabetic Ulcers: An Evidence-Based Review.

Conservative treatment is the basis for diabetic foot ulcer (DFU) management, whereas surgical treatment is usually reserved for patients with failed, recurrent, or nonresponsive infected wounds. However, many reports demonstrated good to excellent results following surgery. Evidence synthesis on surgical offloading techniques and clear guidelines regarding the timing of surgery are lacking. The present study aimed to investigate the evidence behind surgical offloading techniques and propose a cutoff time for surgical indication following failed conservative treatment of neuropathic diabetic forefoot ulcers. Electronic databases were searched from inception to identify the best evidence level articles related to non-vascular surgical treatment of DFUs, such as metatarsal head resection, resection arthroplasty, metatarsal osteotomy, Achilles tendon lengthening, gastrocnemius recession, and flexor tenotomy, that have been employed for managing DFUs. Based on the highest level of evidence available, surgery was found to generate better values than standard conservative care for all outcomes except for the transfer rate. In particular, surgical bony offloading procedures demonstrated significantly better outcomes than standard conservative nonsurgical care in terms of higher healing rates, shorter healing durations, and lower recurrence rates. Moreover, 96% of DFUs healed in <1 month following surgical bony offloading, whereas 68% of ulcers healed within 3 months after standard care. The findings could challenge the classical guidelines of DFU management. This evidence-based review indicates that surgical offloading could be used more often and be proposed earlier during the course of ulcer management. The results imply that a period of 12 weeks could be considered a reasonable cutoff value to consider surgical treatment for patients with nonhealing DFUs.

PO 18105 - Diabetic foot ulcer PEDIS III

Introduction: Infectious agents are associated with amputation of the infected diabetic foot if not promptly treated. It is estimated that 25% of patients with diabetes will present with a foot ulcer at some point of their lives. Our hypothesis is that the microbiological profile isolated from chronic osteomyelitis (CO) secondary to neuropathic foot ulcers is different from the standard profile relayed in the literature. Objective: To determine the microbiological profile and antimicrobial susceptibility patterns of organisms isolated from chronic osteomyelitis (CO) secondary to neuropathic foot ulcers. Furthermore, we aimed to describe the clinical outcomes of 52 patients admitted to a referral diabetic foot center. Methods: Medical charts of 52 patients with clinically infected neuropathic foot ulcers between 2005 and 2013 were reviewed. Osteomyelitis was diagnosed based on suggestive changes on radiographs and magnetic resonance imaging (MRI), and confirmed with a microbiological exam. All cases were followed for at least six months. Only results of bone culture obtained at the time of surgical debridement following antisepsis were considered for microbiological characterization. Results: One hundred and eleven bacterial isolates were identified as causative agents of infection, with a mean 2.13 isolates per patient. There was a predominance of Gram-positive cocci (51%), followed by Gram-negative bacilli (GNB) (43%). The most prevalent agents were Staphylococcus aureus (18%), Enterococcus faecalis (18%) and coagulase-negative Staphylococci (CoNS) (14%). Among S. aureus isolates, the prevalence of methicillin resistance (MRSA) was 48%, and 77% CoNS were methicillin resistant (MRCoNS) with 100% susceptibility to sulfamethoxazole/trimethoprim (SMT/TMP). At 6-month follow-up, 75% of patients were in remission, without signs of infection, 23% of patients presented recurrence of infection, and 2% were lost to follow-up. Conclusion: In diabetic patients with chronic osteomyelitis secondary to neuropathic ulcers, S. aureus, E. faecalis and CoNS were the most frequent agents. The occurrence of MRSA and MRCoNS was high, but with 100% susceptibility to SMT/TMP. Extensive surgical debridement associated with prolonged antimicrobial therapy led to infection remission in 77% of patients after 6 months of follow-up.

Vehicle ergonomics contributing to a diabetic foot ulcer

BackgroundDiabetes mellitus continues to be a rising concern in the United States. It affects an estimated 9.4% of the population and approximately 1.5 million Americans are diagnosed annually. Approximately 85% of diabetic foot ulcers are associated with diabetic peripheral neuropathy and an infected diabetic foot ulcer is often the first sign of diabetes. There are countless studies within the literature that investigate how insensate feet and the manifestation of a foot ulcer further decrease quality of life and increase risk for mortality. Literature focuses on gait and kinematics that contribute to the formation of a diabetic foot ulcer. While pressure and shear forces are etiologic factors that may lead to the formation of diabetic foot ulcers, the position of the foot while driving an automobile has been ignored as a possible risk factor.Case presentationThe clinical case will describe the events of healing a neuropathic diabetic foot ulcer beyond the standard of care treatment plan. It is one of the first case reports to describe vehicle ergonomics as an etiologic factor contributing to a diabetic foot ulcer. Once the patient becomes aware of the unnecessary source of pressure, education and care is provided to manage this likely source of daily pressure to the neuropathic foot.ConclusionThe article emphasizes the importance of a complete assessment, including nontraditional factors, which may lead to diabetic complications.

A 10-year Retrospective Case-Series of Venous Thrombo-Embolism frequency in Patients Treated with Total Contact Casts

Category:DiabetesIntroduction/Purpose:Venous Thrombo-Embolism (VTE) is a recognized complication of lower limb immobilization. In the neuropathic patient total contact casting (TCC) is used in the management of acute charcot neuroathropathy and/or to off-load neuropathic ulcers. To our knowledge, there is currently no literature stating the prevalence of VTE in patients, despite the possibility of prolonged lower limb immobilization. There are also no recommendations regarding VTE prophylaxis in the setting of TCCs. We report a retrospective case series assessing the frequency of symptomatic VTE in the patients treated with TCCs. Given that diabetic foot disease manifests as one of many co-morbidities in this medically complex group of patients we hypothesize that the rate of occurrence of VTE should be higher than that of the general population.Methods:Patients undergoing TCC between 2006 and 2018 were identified using plaster room records. These patients subsequently had electronic clinical letters and radiological reports assessed for details around the TCC episode, past medical history and any VTE events.Results:There were 143 TCC episodes in 105 patients. Average age at cast application was 55 years. The mean time in a cast was 45 days (range from 5 days to 8 months). 3 out of 4 patients had neuropathy as a consequence of diabetes. One TCC related VTE (0.7% of casting episodes) was documented. This was a proximal DVT confirmed on USS 9 days following cast removal. Only 3 patients received VTE prophylaxis while in TCC.Conclusion:Despite these complex patients having a multitude of co-morbidities the frequency of VTE in the TCC setting remains similar to that of the general population. This may be due to the fact that TCCs permit weight bearing or that Charcot arthropathy leads to a high outflow state, potentially turning Virchow’s triad in the patient’s favour. This case series suggests that, while all patients should be individually VTE risk assessed as for any lower limb immobilization, chemical thromboprophylaxis is not routinely indicated in the context of TCCs.

Pressure off-loading Mandakini dressing versus conventional wet gauze dressing in the treatment of neuropathic plantar ulcers: a randomized controlled trial

Background: Plantar ulcers are one of the significant causes of morbidity in diabetic and non- diabetic neuropathic foot and remain a major initiating event for amputation. This randomized controlled trial was carried out to establish the benefits of the 'Mandakini' dressing in comparison with conventional wet gauze dressings, in patients with neuropathic plantar ulcers.Methods: The treatment group received ‘Mandakini’ dressing which was changed every week. Control group received conventional wet gauze dressings. Size of the ulcer, grade of the ulcer and wound surface area was assessed at the end of every week up to 6 weeks in both groups. The percentage of wound covered with granulation tissue, the percentage of wound covered with non-viable tissue and the time taken for healing of the ulcer were compared between the two groups.Results: A total of 60 patients were randomized into treatment and control group with 30 patients in each. The ‘Mandakini’ dressing group had a significant reduction in the wound size at 6 weeks compared to the control group (1.29 vs. 2.31 cm2; p ≤0.0001). Time taken for healing of the ulcer was significantly less in ‘Mandakini’ dressing group (4.83 vs. 5.4 weeks; p=0.013).Conclusions: Mandakini dressing significantly reduces the wound size and time taken for the healing of plantar ulcer compared to conventional wet gauze dressing. Patient acceptability, patient satisfaction, quality of life and cost of the total treatment were better in Mandakini dressing group.

Systemic translation of locally infiltrated epidermal growth factor in diabetic lower extremity wounds.

Diabetic foot ulcer is one of the most frightened diabetic complications leading to amputation disability and early mortality. Diabetic wounds exhibit a complex networking of inflammatory cytokines, local proteases, and reactive oxygen and nitrogen species as a pathogenic polymicrobial biofilm, overall contributing to wound chronification and host homeostasis imbalance. Intralesional infiltration of epidermal growth factor (EGF) has emerged as a therapeutic alternative to diabetic wound healing, reaching responsive cells while avoiding the deleterious effect of proteases and the biofilm on the wound's surface. The present study shows that intralesional therapy with EGF is associated with the systemic attenuation of pro-inflammatory markers along with redox balance recovery. A total of 11 diabetic patients with neuropathic foot ulcers were studied before and 3 weeks after starting EGF treatment. Evaluations comprised plasma levels of pro-inflammatory, redox balance, and glycation markers. Pro-inflammatory markers such as erythrosedimentation rate, C-reactive protein, interleukin-6, soluble FAS, and macrophage inflammatory protein 1-alpha were significantly reduced by EGF therapy. Oxidative capacity, nitrite/nitrate ratio, and pentosidine were also reduced, while soluble receptor for advanced glycation end-products significantly increased. Overall, our results indicate that the local intralesional infiltration of EGF translates in systemic anti-inflammatory and antioxidant effects, as in attenuation of the glycation products' negative effects.

Five-year mortality in patients with diabetic foot ulcer during 2009–2010 was lower than expected

AimMortality rates are decreasing in patients with diabetes. However, as this observation also concerns patients with diabetic foot ulcer (DFU), additional data are needed. For this reason, our study evaluated the 5-year mortality rate in patients with DFU during 2009–2010 and identified risk factors associated with mortality. MethodsConsecutive patients who attended a clinic for new DFU during 2009–2010 were followed until healing and at 1 year. Data on mortality were collected at year 5. Multivariate Cox proportional-hazards model was used to identify mortality risk factors. ResultsA total of 347 patients were included: mean age was 65±12 years, diabetes duration was 16 [10; 27] years; 13% were on dialysis; and 7% had an organ transplant. At 5 years, 49 patients (14%) were considered lost to follow-up. Total mortality rate at 5 years was 35%, and 16% in patients with neuropathy. On multivariate analyses, mortality was positively associated with: age [hazard ratio (HR): 1.05 (1.03–1.07), P<0.0001]; duration of diabetes [HR: 1.02 (1.001–1.03], P=0.03]; PEDIS perfusion grade 2 vs. 1 [HR: 2.35 (1.28–4.29), P=0.006)]; PEDIS perfusion grade 3 vs. 1 [HR: 3.14 (1.58–6.24), P=0.001); and ulcer duration at year 1 [HR 2.09 (1.35–3.22), P=0.0009]. ConclusionMortality rates were not as high as expected despite the large number of comorbidities, suggesting that progress has been made in the health management of these patients. In particular, patients with neuropathic foot ulcer had a survival rate of 84% at 5 years.