Treatment Of Neuropathic Foot Ulcers Research Articles

Offloading systems for the treatment of neuropathic foot ulcers in patients with diabetes mellitus: a meta-analysis of randomized controlled trials for the development of the Italian guidelines for the treatment of diabetic foot syndrome.

To compare the effectiveness of commonly used offloading devices for the treatment of neuropathic foot ulcers in patients with diabetes mellitus. This meta-analysis (MA) has been performed for giving an answer to clinical questions on this topic of the Italian guideline on diabetic foot syndrome. The present MA includes randomized controlled studies (duration > 12weeks) comparing, in patients with diabetes mellitus and non-infected neuropathic foot ulcer: any offloading device vs either no offloading device or conventional footwear; removable versus non-removable offloading devices; surgical procedure vs other offloading approaches. The primary endpoint was ulcer healing. A total of 184 studies were identified, and 18 were considered eligible for the analysis. We found that: any plantar off-loading, when compared to the absence of plantar offloading device, is associated with a higher ulcer healing (MH-OR: 3.13 [1.08, 9.11], p = 0.04, I2 = 0%); total contact cast or nonremovable knee-high walker, compared to other offloading devices, had a higher ulcer healing rate (MH-OR: 2.64 [1.43, 4.89], p = 0.002, I2 = 51%); surgical offloading for active ulcers in combination with post-surgery offloading achieves higher ulcer healing rate when compared to offloading devices alone (MH-OR: 6.77 [1.64, 27.93], p = 0.008, I2 = 0%). Any plantar offloading, compared to the absence of plantar offloading device, is associated with a higher ulcer healing rate. Total contact cast or nonremovable knee-high walker, compared to other offloading devices, is preferable. Surgical offloading for active ulcers, in combination with post-surgery offloading devices, achieves a higher ulcer healing rate when compared to other offloading devices alone. Further studies with a larger cohort of patients with diabetic neuropathic foot ulcers and extended follow-up periods are necessary.

Gastrocnemius fascia release under local anaesthesia as a treatment for neuropathic foot ulcers in diabetic patients: a short series

Background: Diabetic foot ulceration is the leading cause of major amputation in the developed world. Plantar neuropathic ulcers at the forefoot can be managed conservatively with off-loading, but treatment is not invariably successful. Achilles tendon lengthening procedures aim at increasing dorsiflexion and decreasing forefoot pressure but can be associated with complications and require prolonged postoperative immobilization to prevent tendon rupture. We assessed the feasibility and clinical outcome of a comparative minimal invasive procedure: the gastrocnemius fascia release. This technique targets the same goals but is performed under local anaesthesia and allows immediate postoperative weight bearing and ambulation.Methods: Diabetic patients with plantar neuropathic ulcers Wagner grade 2 or 3 were recruited from our diabetic foot clinic. Patients with infected wounds or untreatable peripheral arterial disease were excluded from the study. Conservative treatment with off-loading and local wound care was attempted for six weeks and surgical procedure only contemplated upon failure. Primary end-points were improved range of dorsiflexion and time to healing. Secondary end-points were local ulcer recurrences, new plantar ulcers, and minor or major amputation. Post-operative follow-up was 12 months.Results: Seven patients were included in the study. An improvement in dorsiflexion of 10.4° (mean) was recorded post-operatively (p < 0.01). After 30 days, complete healing was accomplished in six of the seven patients. Long-term results were excellent as no ulcer recurrence or amputation was noted.Conclusions: Gastrocnemius fascia release under local anaesthesia can be performed safely in diabetic patients with plantar neuropathic ulcers under the metatarsal heads. Clinical outcome is excellent and long-term results promising.

Opportunities of predictive medicine at the treatment of diabetes mellitus complications

Foot ulcers develop in approximately 15 percent of type 1 Diabetes patients. 85% of the lower-limb amputations in those patients are preceded by foot ulceration, suggesting that prevention and appropriate management of foot lesions are of marked value. Ulceration is caused by several factors acting together, but particularly by neuropathy. The annual incidence of foot ulceration is slightly larger than 2.0 percent among all T1D patients and between 5.0 and 7.5 percent among T1D patients with peripheral neuropathy [1]. Peripheral neuropathy results in a loss of the protective sensation of pain and in autonomic dysfunction, with sympathetic denervation, dry skin, and warm feet. Appropriate medical education regarding early assessment for lesions or warning signs of imminent ulceration in patients with sensory loss is essential for the future to come. Other important component causes of ulceration include peripheral vascular disease, callus, edema, and deformity. The triad of neuropathy, deformity, and trauma is present in almost two thirds of patients with foot ulcers. Inappropriate footwear is the most common source of trauma [2]. The economic burden associated with diabetic foot ulceration, i.e., a condition that is preventable in many cases, is enormous. The estimated cost of treating one foot ulcer over a two-year period is $28,000. Growth Factors Recombinant platelet-derived growth factor was the first growth factor approved by FDA for the treatment of neuropathic foot ulcers in T1D patients. A recent review of growth factors in the treatment of diabetic foot ulcers concluded that, platelet-derived growth factor may be useful in chronic, non healing europathic ulcers that do not respond to conventional care [3]. Tissue-engineered skin comprises a cultured living dermis and sequentially cultured epidermis, the cellular components of which are derived from neonatal foreskin. Treatment with tissue-engineered skin is associated with faster healing and lower rates of osteomyelitis and lower-limb amputation [4]. Alternative insulin therapies are being sought that will provide glycemic control for people with diabetes mellitus. The epidermis is a self-renewing tissue that is easily accessible and can provide large numbers of autologous cells that can be used for generating insulin-secreting skin substitutes. Lentiviral vectors have been engineered to produce a fusion protein between the furin-cleavable proinsulin and the self-dimerization mutant of FK506-binding protein to yield bioactive insulin in keratinocytes; this insulin is released as a response to exogenous administration of a small organic molecule, rapamycin [5]. The bioengineered keratinocytes retained normal morphology and grew in a manner similar to lentiviral-treated control cells. There are a lot of products of bioengineering, different scaffolds, which can be used as base for tissue regenerating. From our point of view, one of the main points of preventive effect in the treatment of diabetes is to secure early accumulation of the personalized genetic information about the patient. This is necessary not only for treatment of the underlying disease, but treatment of its complications. Modern technologies allow creating biomaterials that can provide not only local, but also the overall therapeutic effect when they are implanted in the area of ulceration in diabetes.

The “Rigid Rocker” Posterior Shell Orthosis

ABSTRACTCurrent treatment of neuropathic foot ulcers focuses on pressure offloading. The total contact cast (TCC) is the criterion standard offloading treatment because it provides pressure relief, limits activity, and enforces adherence. However, TCCs are time consuming and resource intensive and p

Use of the Charcot Restraint Orthotic Walker in Treatment of Neuropathic Foot Ulcers

Although the total contact cast is the criterion standard for the pressure redistribution of challenging foot ulcers, in practice it is not often feasible. The following is a case series that demonstrates an encouraging possibility for the Charcot restraint orthotic walker as a device to be used in more challenging forefoot ulcers.

Effect of Pulsed Nd:YAG Laser in the Treatment of Neuropathic Foot Ulcers in Children with Spina Bifida: A Randomized Controlled Study

This study assessed the effects of pulsed Nd:YAG laser treatment of neuropathic foot ulcers in children with spina bifida. Children with spina bifida face increased risk for developing neuropathic foot ulcers. In a randomized controlled trial, 39 children and adolescents (ages 6-15 years) with spina bifida and stage III neuropathic foot ulcers were randomly assigned to the laser group or the placebo laser group. The former received pulsed Nd:YAG laser treatments (i.e., total energy of 300-350 J during three sessions/week) plus standard wound care, and the latter received sham laser treatments plus standard wound care. Wound size and wound appearance were assessed for all patients at the beginning of the treatment, after 5 weeks, and after 10 weeks. The decrease in wound surface area at 5 and 10 weeks post- treatment was significantly greater in the laser group (i.e., 2.44 ± 0.33 and 0.29 ± 0.25 cm(2), respectively) than in the placebo group (i.e., 3.81 ± 0.18 and 3.24 ± 0.44 cm(2), respectively). Also, the decrease in the total score for the Pressure Sore Status Tool (PSST) at 5 and 10 weeks post-treatment was significantly different for the laser group (i.e., 32.76 ± 2.30 and 17.52 ± 1.66, respectively) than for the placebo group (i.e., 46.50 ± 2.12 and 38.11 ± 3.17, respectively). Treatment with pulsed neodymium:yttrium aluminum garnet (Nd:YAG) laser combined with standard wound care decreases wound size and improves wound appearance for stage III neuropathic foot ulcers in children with spina bifida.

Comparison of the clinical effectiveness of different off‐loading devices for the treatment of neuropathic foot ulcers in patients with diabetes: a systematic review and meta‐analysis

Effective off-loading is considered to be an important part of the successful clinical management of diabetic foot ulcers. The aim of this systematic review is to investigate the safety and effectiveness of different off-loading devices for the treatment of diabetic foot ulcers. The medical literature was extensively searched from January 1966 to May 2012. Systematic reviews and controlled studies that compared the use of different off-loading devices formed the evidence base. Studies were critically appraised to determine their risk of methodological bias, and data were extracted. Results were pooled using random effects meta-analysis and tested for heterogeneity. When compared with removable devices, non-removable off-loading devices were found, on average, to be more effective at promoting the healing of diabetic foot ulcers (RRp = 1.43; 95% CI 1.11, 1.84; I(2) = 66.9%; p = 0.001; k = 10). Analysis, stratified by type of removable device, did not detect a statistically significant difference between non-removable off-loading devices and removable cast walkers; however, on average non-removable off-loading devices performed better than therapeutic shoes at promoting the healing of diabetic foot ulcers (RRp = 1.68; 95% CI 1.09, 2.58; I(2) = 71.5%; p = 0.004; k = 6). The two types of non-removable off-loading devices i.e. total contact casts and instant total contact casts (removable cast walker rendered irremovable by securing with bandage or lace), were found to be equally effective (RRp = 1.06; 95% CI 0.88, 1.27; I(2) = 3.3%; p = 0.31; k = 2). In conclusion, non-removable off-loading devices regardless of type, are more likely to result in ulcer healing than removable off-loading devices, presumably because patient compliance with off-loading is facilitated.

Diabetic foot wound care algorithms.

The purpose of this article is to present reference guidelines to assist clinicians when treating diabetic patients with foot wounds. Diabetic patients with limb-threatening foot ulcers often have multiple coexisting medical conditions that frequently become impediments to the resolution of foot wounds. Each foot wound is unique and its etiology is multifactorial; therefore, each foot wound should be managed differently. The treatment algorithm presented in this article is divided into three categories: Algorithm I describes the treatment of septic foot wounds, which may be considered true podiatric surgical emergencies; Algorithm II describes the treatment of ischemic foot ulcers or gangrene with or without underlying osteomyelitis; and Algorithm III describes the treatment of neuropathic foot ulcers with or without underlying osteomyelitis.