Nonischemic Diabetic Foot Research Articles

Clinical Effects of Thread-Dragging Therapy on Gangrene of Non-ischemic Diabetic Foot Ulcers.

To investigate the clinical effects of thread-dragging therapy on gangrene of non-ischemic diabetic foot ulcers (NIDFU). A total of 136 patients with NIDFU were recruited from the Department of Peripheral Vascular Surgery, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine between June 21, 2021 and February 1, 2023, and randomized into an intervention group and a control group, with 68 cases in each group. Both groups received basic treatment. The intervention group was treated with thread-dragging therapy, while the control group was treated with debridement combined with routine dressing changes after surgery. Both groups were treated continuously for 2 months. The amputation rates and changes in the ulcer area were compared between the groups. The inflammatory response index including peripheral white blood cells (WBCs), neutrophil percentage (NEUT%), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT), and interleukin 6 (IL-6) were compared between the two groups. After treatment, the ulcer areas in the intervention group were significantly smaller than that of the control group (8.50±3.88 cm2 vs. 10.11±4.61 cm2, P<0.05). The amputation rates of the two groups were not statistically significant (4.4% vs. 5.9%, P>0.05). Differences of WBCs count, CRP, and ESR before and after therapy in the intervention group were better than the control group (P<0.05). However, there were no significant differences in changes of NEUT%, PCT, and IL-6 between the two groups (P>0.05). Thread-dragging therapy may be effective in the treatment of NIDFU, with the additional advantages of less tissue damage after healing. (Registration No. ChiCTR2100047496).

Outcomes of Keller Gap Arthroplasty for Plantar Hallux Interphalangeal Joint Ulcers in Patients With Diabetes Mellitus.

Hallux ulcers are known for their recurrence and associated risk for future amputations. Traditional nonsurgical external offloading methods have poor compliance rates, and the data is sparse on surgical offloading of hallux ulcers. We performed this study to analyze the outcomes of Keller excision gap arthroplasty of the first metatarsophalangeal joint in patients with a neuropathic plantar hallux interphalangeal joint (IPJ) ulcer in patients with diabetes mellitus. A retrospective study of 105 diabetic patients with a plantar hallux IPJ ulcer who underwent a Keller excision gap arthroplasty between December 2014 and June 2020 was done. A total of 122 great toes had been operated upon for hallux IPJ ulcers. We studied the long-term wound healing rates from patient records and then did a prospective survey of the postreview period. All the hallux IPJ ulcers healed well in the immediate postoperative period. Six patients reported a recurrence of the ulcer at the original site during a mean follow-up period of 30 months. For these 6 patients, the mean time to recurrence of ulcer after operation was 2.5 years. At an average of 30 months, we found the Keller gap arthroplasty for treatment of noninfected and nonischemic diabetic foot hallux IPJ ulcers was associated with an ulcer recurrence rate of 5%. Level IV, cohort study.

Arterial spin labeling magnetic resonance imaging quantifies tissue perfusion around foot ulcers.

Tools that quantify tissue perfusion of the foot are deficient, contributing to the uncertainty in predicting ulcer healing potential. This pilot study aims to quantify peri-wound foot perfusion at various tissue depths using a novel application of pseudo-continuous arterial spin labeling magnetic resonance imaging. Ten diabetic patients with neuropathic wounds and 20 healthy volunteers without wounds were recruited. Wounds were graded according to the Wound, Ischemia, Foot Infection (WIfI) system. All subjects underwent a noncontrasted ASL MRI of the foot for perfusion measurements. For healthy volunteers, perfusion was compared at rest and during sustained toe flexion between four regions: lateral plantar, medial plantar, lateral calcaneal, and medial calcaneal. Evaluations of diabetic volunteers compared perfusion between four zones: wound, near border, far border, and remote. Remote zone perfusion in diabetics was compared with perfusion in the plantar foot of healthy volunteers. There were 11 wounds, which were located over the metatarsal heads in five, the stump of a transmetatarsal amputation in three, the heel in two, and the mid foot in one. The median WIfI stage was 2. One patient had a WIfI ischemia grade of 1; the remaining patients' grades were 0. The mean ankle-brachial index was 1.0± 0.3. There were two patients with a WIfI foot infection grade of 1; the remaining patients' grades were 0. In healthy volunteers, plantar foot perfusion with sustained toe flexion was 43.9± 1.7mL/100g/min and significantly higher than perfusion at rest (27.3± 2.7mL/100g/min; P< .001). In diabetic patients, perfusion at the wound, near border, far border, and remote regions was 96.1± 10.7, 92.7± 9.4, 73.4± 8.2, and 62.8± 2.7mL/100g/min. Although this perfusion pattern persisted throughout the depth of the wound, perfusion decreased with tissue depth. In the near border, perfusion at 20% of the wound depth was 124.0± 35.6mL/100g/min and 69.9± 10.1mL/100g/min at 100% (P= .006). Lastly, remote perfusion in diabetics was 2.3 times the plantar perfusion in healthy volunteers (27.3± 2.7mL/100g/min; P< .001). The pattern of resting tissue perfusion around nonischemic diabetic foot ulcers was successfully quantified with arterial spin labeling magnetic resonance imaging. Diabetic patients with wounds were hyperemic compared withhealthy volunteers. There was a 1.5-fold increase in peri-wound tissue perfusion relative to the rest of the foot. This study is the first step in developing a tool to assess the perfusion deficit in ischemic wounds.

The Past, Present, and Future of Podiatry.

The Past, Present, and Future of Podiatry.

A Comparative Study of Xi's Tendon Gangrene (Nonischemic Type of Diabetic Foot) and Gangrene (Diabetic Foot Ischemic Type).

Background Diabetic foot gangrene refers to a lesion in which the tissue of the foot or lower extremities of diabetic patients is damaged, and the cause is the infection of peripheral blood vessels and neuropathy caused by diabetes. Objective To compare the related indexes of blood glucose, inflammation, blood viscosity, and peripheral neuropathy between the nonischemic diabetic foot and ischemic diabetic foot, the same and different characteristics of the two different types of diabetic foot in pathogenesis were discussed and studied. Methods A total of 122 patients with diabetic foot were selected from the Department of Vascular Medicine, Shanghai Hospital of Integrated Traditional Chinese and Western Medicine, including 61 cases of ischemic type and 61 cases of nonischemic type. The differences in blood glucose, inflammation, blood supply, and peripheral neuropathy between the nonischemic diabetic foot and ischemic diabetic foot were compared to explore their different characteristics. Results The blood glucose index, inflammatory index, and plasma fibrinogen in patients with nonischemic diabetic foot were significantly higher than those in patients with ischemic diabetic foot (P < 0.05). The patients with ischemic diabetic foot were higher in age and blood lipid index than those with the nonischemic diabetic foot (P < 0.05), while having no significant difference in platelet count, plasma viscosity, hematocrit, and end products of glycation (AGEs). Conclusion The nonischemic diabetic foot is mainly infective necrosis, and the ischemic type is ischemic necrosis. The former occurs in the middle-aged and elderly with good blood supply between 40 and 60 years old, while the latter occurs in the elderly with the severe vascular disease over 60 years old. The blood glucose level of nonischemic patients is significantly higher than that of ischemic patients, but it has little to do with the course of diabetes.

Autologous Platelet Rich Plasma Promotes the Healing of Non-Ischemic Diabetic Foot Ulcers. A Randomized Controlled Trial

DFU (diabetic foot ulcer) represents a major global health and socioeconomic problem and a leading cause of lower limb amputation. Although many therapies have been tested, none has been proposed as a dominant wound healing treatment. We performed a prospective randomized controlled study in order to assess the role of autologous platelet rich plasma (PRP) for the promotion of non-ischemic DFU healing. After full vascular assessment, a total of 80 patients were randomized in 1:1 ratio to receive either PRP injection in the healing edge and the floor of the targeted DFU (Group A), or have usual standard care with moist dressing with or without collagenase ointment (Group B). We calculated the total surface area (TSA) for the ulcer in both groups (cm2) before, after treatment and every week up to 12 weeks of follow-up. A total of 4 patients (10%) experienced major amputation in group B, while no major amputation was performed in patients of Group A (P< 0.001). A ≥ 50% reduction in TSA occurred earlier in Group A (at 2.5 weeks), compared to Group B (4.5 weeks); P < 0.001. Complete wound healing rate was 95% (n=38) and it was achieved earlier (6th week) for patients of group A, contrary to 77.8% (n=28) of patients (9th week) for Group B (P < 0.001). Superficial wound infection was noted in 10% (n=4) of the cases in the PRP arm, while in group B, 45% (n=18) of cases had a variable degree of infection ranging from superficial to deep wound infection and cellulites (P < 0.001). PRP treatment was cost-effective, with 247.50$ vs. 437.50$ for the total cost of treatment for patients of Group B. PRP is a cost-beneficial novel modality of treatment that can accelerate wound healing and decrease the rate of local infection in DFU, compared to other conventional treatment modalities.

Comparative Study Between Silver Nanoparticles Dressing (SilvrSTAT Gel) and Conventional Dressing in Diabetic Foot Ulcer Healing: A Prospective Randomized Study.

We are trying to evaluate silver nanoparticles' effectiveness (SilvrSTAT Gel) in accelerating healing rate of nonischemic diabetic foot ulcers (DFUs). This prospective, double-blind, randomized, controlled study includes 80 patients with nonischemic DFUs classified into 2 groups. Group A was subjected to SilvrSTAT Gel dressing, and group B was subjected to conventional dressing (wet-to-moist dressing with or without povidone-iodine). All cases had minimal debridement before treatment. In both groups, all cases were nonischemic after successful revascularization either by bypass surgery or endovascular therapy. The healing rate of the SilvrSTAT group was significantly higher than that of the conventional group. The healing rate per week of the SilvrSTAT group was considerably higher than that of the conventional group (P < .0001). The rate of complete healing for ulcers in group A was achieved in 22 patients (55%) by the 6th week, while 29 (72.5%), 34 (85%), and 36 (90%) patients were healed entirely by the 8th, 10th, and 12th weeks, respectively. In group B: 20 (50%), 27 (67.5%), and 30 (75%) patients were completeley healed by the 8th, 10th, and 12th weeks, respectively. SilvrSTATGel is effective in the treatment of DFU.

Hyperbaric oxygen therapy for nonischemic diabetic ulcers: A systematic review.

ABSTRACTDiabetic foot ulcers are a common complication of diabetes, which affects 25% of patients and may ultimately lead to amputation of affected limbs. Research suggests hyperbaric oxygen therapy improves healing of these ulcers. However, this has not been reflected in previous reviews, possibly because they did not differentiate between patients with and without peripheral arterial occlusive disease. Therefore, we performed a systematic review of published literature in the MEDLINE, Embase, and Cochrane CENTRAL databases on nonischemic diabetic foot ulcers with outcome measures including complete ulcer healing, amputation rate (major and minor), and mortality. Seven studies were included, of which two were randomized clinical trials. Two studies found no difference in major amputation rate, whereas one large retrospective study found 2% more major amputations in the hyperbaric oxygen group. However, this study did not correct for baseline differences. Two studies showed no significant difference in minor amputation rate. Five studies reporting on complete wound healing showed no significant differences. In conclusion, the current evidence suggests that hyperbaric oxygen therapy does not accelerate wound healing and does not prevent major or minor amputations in patients with a diabetic foot ulcer without peripheral arterial occlusive disease. Based on the available evidence, routine clinical use of this therapy cannot be recommended. However, the available research for this specific subgroup of patients is scarce, and physicians should counsel patients on expected risks and benefits. Additional research, focusing especially on patient selection criteria, is needed to better identify patients that might profit from this therapy modality.

Assessment of Hydroxyproline Levels in Non-Ischemic Diabetic Foot Ulcers During Recovery. A Prospective Case-Control Study

Abstract Background and aims: Proline hydroxylation is essential for collagen synthesis in wound healing. Therefore, hydroxyproline quantification may be a suitable marker of wound healing in diabetic tissue. Material and method: This is a prospective casecontrol clinical study including 90 referral patients from our clinics in Golestan hospital affiliated to Jundishapour Medical University, Ahwaz-Iran, during a period of 18 months. Three groups were recruited: intervening diabetics with non-ischemic foot ulcers, diabetics without foot ulcers (normal diabetics) and non-diabetics without foot ulcers (normal non-diabetics) as control groups (n=30 per group). 500 mg of granulation tissue from ulcers after treatment and 500 mg of normal skin from both control groups were taken for the measurement of hydroxyproline levels. Results: 13 (43.3%) males and 17 (56.7%) females in trial group were analysed. There was no significant differences in age, gender, and BMI between groups. Mean hydroxyproline concentration in wound granulation tissue (140.44 μg/g) was statistically different from the mean concentration in the skin content of normal diabetics (173.22 g/g,) and the skin content of nondiabetics (178.83 μg/g) (p=0.001). There were no statistically significant differences between the mean values of normal diabetics and non-diabetics (p=0.63). Conclusion: Our results showed the presence of a lower quantity of hydroxyproline in diabetic patients with foot ulcers compared to control groups. This raises the issue of its effectiveness in delaying the repair process in diabetics. Therefore, compensating for tissue hydroxyproline deficit can be a clue in improving diabetic tissue repair.

Prediction of Healing for Postoperative Diabetic Foot Wounds Based on Early Wound Area Progression

To evaluate the probability of wound healing based on percentage of wound area reduction (PWAR) at 1 and 4 weeks in individuals with large, chronic, nonischemic diabetic foot wounds following partial foot amputation. Data from a 16-week randomized clinical trial (RCT) of 162 patients were analyzed to compare outcomes associated with negative-pressure wound therapy (NPWT) delivered through the V.A.C. Therapy System (Kinetic Concepts, San Antonio, TX) (n = 77) versus standard moist wound therapy (MWT) (n = 85). The 1- and 4-week regression models included 153 and 129 of the RCT patients, respectively. Early changes in PWAR were predictive of final healing at 16 weeks. Specifically, wounds that reached >or=15% PWAR at 1 week or >or=60% PWAR at 4 weeks had a 68 and 77% (respectively) probability of healing vs. a 31 and 30% probability if these wound area reductions were not achieved. Patients receiving NPWT were 2.5 times more likely to achieve both a 15% PWAR at 1 week and a 60% area reduction at 1 month (odds ratios 2.51 and 2.49, respectively) compared with those receiving MWT. Results of this study suggest that clinicians can calculate the PWAR of a wound as early as 1 week into treatment to predict the likelihood of healing at 16 weeks. This might also assist in identifying a rationale to reevaluate the wound and change wound therapies.

Efficacy of Fifth Metatarsal Head Resection for Treatment of Chronic Diabetic Foot Ulceration

This study compares the potential benefit of fifth metatarsal head resection versus standard conservative treatment of plantar ulcerations in people with diabetes mellitus. Using a retrospective cohort model, we abstracted data from 40 patients (22 cases and 18 controls) treated for uninfected, nonischemic diabetic foot wounds beneath the fifth metatarsal head. There were no significant differences in sex, age, duration of diabetes mellitus, or degree of glucose control between cases and controls. Patients who underwent a fifth metatarsal head resection healed significantly faster (mean +/- SD, 5.8 +/- 2.9 versus 8.7 +/- 4.3 weeks). Patients were much less likely to reulcerate during the period of evaluation in the surgical group (4.5% versus 27.8%). The results of this study suggest that fifth metatarsal head resection is a potentially effective treatment in patients at high risk of ulceration and reulceration.

Use of subatmospheric (VAC) therapy to improve bioengineered tissue grafting in diabetic foot wounds.

The use of bioengineered tissue and topical subatmospheric pressure therapy have both been widely accepted as adjunctive therapies for the treatment of noninfected, nonischemic diabetic foot wounds. This article describes a temporally overlapping method of care that includes a period of simultaneous application of bioengineered tissue (Apligraf, Novartis Pharmaceuticals Corp, East Hanover, New Jersey) and subatmospheric pressure therapy delivered through the VAC (Vacuum Assisted Closure) system (KCI, Inc, San Antonio, Texas). Future descriptive and analytic works may test the hypothesis that combined therapies used at different and often overlapping periods during the wound-healing cycle may be more effective than a single modality.

Healing of diabetic foot ulcers and pressure ulcers with human skin equivalent: a new paradigm in wound healing.

In patients with diabetic foot and pressure ulcers, early intervention with biological therapy will either halt progression or result in rapid healing of these chronic wounds. In a prospective nonrandomized case series, 23 consecutive patients were treated with human skin equivalent (HSE) after excisional debridement of their wounds. A single university teaching hospital and tertiary care center. Twenty-three consecutive patients with a total of 41 wounds (1.0-7.5 cm in diameter) were treated with placement of HSE after sharp excisional debridement. All patients with pressure ulcers received alternating air therapy with zero-pressure alternating air mattresses. Time to 100% healing, as defined by full epithelialization of the wound and by no drainage from the site. Seven of 10 patients with diabetic foot ulcers had complete healing of all wounds. In these patients 17 of 20 wounds healed in an average of 42 days. Seven of 13 patients with pressure ulcers had complete healing of all wounds. In patients with pressure ulcers, 13 of 21 wounds healed in an average of 29 days. All wounds that did not heal in this series occurred in patients who had an additional stage IV ulcer or a wound with exposed bone. Twenty-nine of 30 wounds that healed did so after a single application of the HSE. In diabetic ulcers and pressure ulcers of various durations, the application of HSE with the surgical principles used in a traditional skin graft is successful in producing healing. The high success rate with complete closure in these various types of wounds suggests that HSE may function as a reservoir of growth factors that also stimulate wound contraction and epithelialization. If a wound has not fully healed after 6 weeks, a second application of HSE should be used. If the wound is not healing, an occult infection is the likely cause. All nonischemic diabetic foot and pressure ulcers that are identified and treated early with aggressive therapy (including antibiotics, off-loading of pressure, and biological therapy) will not progress.