Association between diabetic retinopathy and diabetic foot ulcer in patients with diabetes: A meta-analysis

This study aimed to explore the relationship between diabetic retinopathy (DR) and diabetic foot ulcers (DFUs) to provide evidence for the prevention of diabetic complications. PubMed, EMBASE, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database and Wanfang Data databases were searched from their inception until March 2023 for studies on the relationship between DR and DFU. Two researchers independently screened the literature and extracted data according to the inclusion and exclusion criteria. The meta-analysis was performed using the RevMan 5.3 software. Eleven articles referring to 10 208 patients were included, of whom 2191 patients had DFU and 8017 patients did not have DFU. The meta-analysis results showed that DR significantly increased the incidence of DFU (47.94% vs. 16.38%; OR, 4.13; 95% CI, 2.33-7.33; p < 0.001). The results of this study suggest that patients with DR have a higher risk of developing DFU, highlighting the importance of regular screening for these two complications to prevent serious adverse outcomes of diabetes. However, further high-quality studies are required to validate the conclusions of the present study.

Diabetes foot complications and standardized mortality rate in type 2 diabetes

AIM

To quantify the impact of foot complications on mortality outcomes in people with type 2 diabetes (T2D), and how routinely measured factors might modulate that risk.

MATERIALS AND METHODS

Data for individuals with T2D for 2010-2020, from the Salford Integrated Care Record (Salford, UK), were extracted for laboratory and clinical data, and deaths. Annual expected deaths were taken from Office of National Statistics mortality data. An index of multiple deprivation (IMD) adjusted the standardized mortality ratio (SMR_IMD). Life years lost per death (LYLD) was estimated from the difference between expected and actual deaths.

RESULTS

A total of 11 806 T2D patients were included, with 5583 new diagnoses and 3921 deaths during 2010-2020. The number of expected deaths was 2135; after IMD adjustment, there were 2595 expected deaths. Therefore, excess deaths numbered 1326 (SMR_IMD 1.51). No foot complications were evident in n = 9857. This group had an SMR_IMD of 1.13 and 2.74 LYLD. In total, 2979 patients had any foot complication recorded. In this group, the SMD_IMR was 2.29; of these, 2555 (75%) had only one foot complication. Patients with a foot complication showed little difference in percentage HbA1c more than 58 mmol/mol. In multivariate analysis, for those with a foot complication and an albumin-to-creatinine ratio of more than 3 mg/mmol, the odds ratio (OR) for death was 1.93, and for an estimated glomerular filtration rate of less than 60 mL/min/1.73m2 , the OR for death was 1.92.

CONCLUSIONS

Patients with T2D but without a foot complication have an SMR_IMD that is only slightly higher than that of the general population. Those diagnosed with a foot complication have a mortality risk that is double that of those without T2D.

"They say to me 'You want to be a high shot and be like a tourist' so I stopped wearing shoes at home even though I know it is to protect my feet". The perceptions of patients on foot complications

BACKGROUND

Diabetic Foot Ulceration (DFU) is one of the serious complications for people with diabetes and it is also the most devastating but yet preventable complication. This study aimed to explore the perceptions of Type 2 Diabetes Mellitus (T2DM) patients on their foot complications and foot care practices in Fiji.

METHODS

A qualitative study design was used to recruit T2DM patients attending Diabetic clinic in Rotuma Hospital, Fiji from July to September, 2021. Purposive sampling was used to recruit 27 patients until data saturation is happened. Semi-structured one-on-one in-depth interviews that were audio-recorded were used to collect data which was then transcribed and manually analyzed using thematic analysis method.

RESULTS

This study found four main themes namely Knowledge and its determinants, Perceptions on personal practice and health care practice, Health seeking behaviors and Factors affecting footwear practices. T2DM patients had varying levels of knowledge about DFU and these levels of knowledge were attributed to lack of advice from healthcare providers, personal beliefs, culture and societal norms and lack of resources. Patients continued to practice self-care practices that they perceived to protect their feet from trauma and such practices have been passed down through a traditional knowledge system including stigma and beliefs. Culture and personal habits greatly impacted the practice of wearing footwear. Societal norms and traditions greatly impact how T2DM patients take care of their feet and their health in general.

CONCLUSION

Understanding personal beliefs and traditional influences surrounding the patients' environment is paramount in order to effectively implement public health prevention strategies against DFU.

Redefining Foot Symptoms in a Kidney-Pancreas-Transplanted Type 1 Diabetic Patient: Challenging the Conventional Charcot Foot Diagnosis

BACKGROUND Acute Charcot foot can be difficult to diagnose, especially because of other alternate diagnoses that can mimic this condition, particularly stress fracture and acute bone and joint infections, which are 2 conditions that require immediate management. Here, we present the case of a patient who received kidney-pancreas-transplantation for type 1 diabetes mellitus, who consulted for right foot pain after walking. CASE REPORT Our patient was a 47-year-old man who had benefited from a kidney-pancreas transplantation in 2014 for type 1 diabetes and terminal kidney failure and was recently followed for a right foot plantar ulcer that was fully healed. He later presented for right foot pain after walking. Clinical examination showed a red, swollen, and warm foot. Blood test results were unremarkable. Imaging (X-ray/MRI) revealed features compatible with acute Charcot foot. The management consisted of prompt right-foot offloading followed by physiotherapy and adapted orthopedic insoles. CONCLUSIONS This case shows the successful treatment of an active phase of Charcot foot, which avoided the classic transition to chronic Charcot foot with severe osteoarticular destruction. Arguments were developed to rule out other possible diagnoses. The underlying mechanisms of Charcot foot in diabetic patients are related to the neurological and micro-vascular complications induced by poor glycemic control, but the mechanisms are unclear. This case report may help clinicians to better understand and consider another less known and less frequent diagnosis when faced with these clinical features.

Identification of contributing factors, microorganisms and antimicrobial resistance involved in the complication of diabetic foot ulcer treatment

Diabetic foot ulcer (DFU) is a neurological and peripherical complication of diabetes with unknown etiology that is often associated with polymicrobial infections. The present study was conducted to investigate the contributing factors in 285 DFU patients, which included 200 patients with diabetic foot infections (DFI). Identification and characterization of infecting bacterial isolates were done followed by assessment of their pattern of susceptibility to commonly used antibiotics. Among the studied subjects, type 2 diabetes mellitus (T2DM), ulcer type, depth, grade, loss of sensation, infection type, affected foot, recurrence, smoking status, Body Mass Index (BMI), and obesity levels revealed significant disease risk association. Ulcer grades 1 and 2 were more common in males while grade 3 in females. Recurrent infections were significantly higher in females (P = 0.03). Diabetic duration, hyperglycemia, ulcer type, infection type and BMI were positively correlated with delayed wound healing. In DFI samples, 40.2% consisted of gram-negative bacteria, with Pseudomonas aeruginosa (37.5%) being the most common, while in the 60% gram-positive isolates Staphylococcus aureus (40.5%) was the predominant species. Staphylococcus epidermidis was found more frequently in females (P = 0.05). The isolated bacterial strains presented higher resistance against the tested antibiotics; however, ceftriaxone was effective against most of the pathogens. In the current study T2DM along with diabetes duration, obesity, ulcer severity with polymicrobial infection was found to play a strong role in DFI development, where gender predisposition was also observed in ulcer grade and infection. DFI was correlated with loss of sensation, infection type, affected foot, smoking status, BMI and obesity levels.

Comparative Efficacy of Conservative Surgery vs Minor Amputation for Diabetic Foot Osteomyelitis

BACKGROUND

There is uncertainty regarding the optimal surgical intervention for diabetic foot osteomyelitis (DFO). Conservative surgery-amputation-free resection of infected bone and soft tissues-is gaining traction as an alternative to minor amputation. Our primary objective was to explore the comparative effectiveness of conservative surgery and minor amputations in clinical failure risk 1 year after index intervention. We also aimed to explore microbiological recurrence at 1 year, and revision surgery risk over a 10-year study period.

METHODS

Retrospective, single-center chart review of DFO patients undergoing either conservative surgery or minor amputation. We used multivariable Cox regression and Kaplan-Meier estimates to explore the effect of surgical intervention on clinical failure (recurrent diabetic foot infection at surgical site within 1 year after index operation), microbiological recurrence at 1 year, and revision surgery risk over a 10-year follow-up period.

RESULTS

651 patients were included (conservative surgery, n = 121; minor amputation, n = 530). Clinical failure occurred in 34 (28%) patients in the conservative surgery group, and in 111 (21%) of the minor amputation group at 1 year (P = .09). After controlling for potential confounders, we found no association between conservative surgery and clinical failure at 1 year (adjusted hazard ratio [HR] 1.3, 95% CI 0.8-2.1). We found no between-group differences in microbiological recurrence at 1 year (conservative surgery: 8 [6.6%]; minor amputation: 33 [6.2%]; P = .25; adjusted HR 1.1, 95% CI 0.5-2.6). Over the 10-year period, the conservative group underwent significantly more revision surgeries (conservative surgery: 85 [70.2%]; minor amputation: 252 [47.5%]; P < .01; adjusted HR 1.3, 95% CI 0.9-1.8).

CONCLUSION

We found that with comorbidity-based patient selection, conservative surgery in the treatment of DFO was associated with the same rates of clinical failure and microbiological recurrence at 1 year, but with significantly more revision surgeries during follow-up, compared with minor amputations.

LEVEL OF EVIDENCE

Level III, retrospective comparative effectiveness study.

Successful Outpatient Treatment of Severe Diabetic-Foot Myositis and Osteomyelitis Caused by Extensively Drug-Resistant Enterococcus faecalis with Teicoplanin plus Rifampicin: A Case Report

BACKGROUND Foot ulcers are high-morbidity and debilitating complications of diabetes mellitus, and carry significantly increased rates of associated major amputations. They contribute to significantly worse quality of life. Osteomyelitis is a frequent complication of diabetic foot ulcers, since bacteria can contiguously spread from soft tissues to the bone, involving the cortex first and then the bone marrow. Unfortunately, clinically unsuspected osteomyelitis is frequent in persisting diabetic foot ulcers. It is associated with limb amputations and increased mortality. CASE REPORT We describe a 76-year-old man with long-standing insulin-treated type 2 diabetes, who experienced extensively drug-resistant Enterococcus faecalis diabetic foot myositis and osteomyelitis associated with sepsis. He was successfully treated with surgical debridement combined with the administration of teicoplanin plus rifampicin in the outpatient setting, completing, in total, a twelve-week course of antibiotic therapy. CONCLUSIONS Clinically unsuspected osteomyelitis in patients with persisting diabetic foot ulcers has been associated with infections from highly resistant bacteria. Early and accurate diagnosis of diabetic foot osteomyelitis, as well as proper therapeutic approach (antimicrobial and surgical), is of great importance to reduce the risk of minor and major amputations, septic shock leading to multiple organ failure, and overall mortality.

Free Tissue Transfer in Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis

OBJECTIVE

Free tissue transfer is a powerful reconstructive method for patients with substantial diabetic foot ulcers. This study aimed to perform an updated systematic review and meta-analysis investigating the flap characteristics, concurrent revascularisation rates, complications, and outcomes associated with free tissue transfer in diabetic foot ulcers.

METHODS

Two reviewers performed a systematic review of various databases since their inception, with no language restriction. Only data for free tissue transfer in non-traumatic diabetic foot ulcer patients were extracted from included studies where a heterogeneous population was studied. Outcome data were pooled using random effects meta-analysis for binomial data.

RESULTS

Of 632 studies identified, 67 studies encompassing 1 846 patients and 1 871 free flaps were included. A median of 18 patients [IQR 9, 37] per study, with a median age of 58.5 years [56, 63], were followed up for a median of 15 months [7, 25]. Most studies had serious risk of bias (n = 47 studies, 70%); sixteen (24%) had moderate risk of bias; and four (6%) had low risk of bias. The proportion of patients who underwent revascularisation was 75% (95% CI 60 - 87%; n = 36 studies) with a median time of 8 days between procedures. The pooled complete flap survival, major amputation, and ambulation rates were 88% (85 - 92%, n = 49 studies), 10% (7 - 14%, n = 50 studies), and 87% (80 - 92%, n = 36 studies), respectively. Death at individual study follow up was 6% (3 - 10%, n = 26 studies). The overall certainty of evidence was very low.

CONCLUSION

Free tissue transfer may be a useful treatment modality for recalcitrant diabetic foot ulcers in selected patients. Future studies should investigate long term functional outcomes and aim to develop patient selection algorithms to select the most suitable candidates for this procedure.

Analyses of transcutaneous oxygen pressure values stratified for foot angiosomes to predict diabetic foot ulcer healing

AIMS

Previous research suggested that diabetic foot ulcer (DFU) location could affect transcutaneous oxygen pressure (TcPO2) values following the angiosome concept. Up to our knowledge no studies have yet analyzed if the location of a diabetic foot ulcer can be a confounding factor that modifies TcPO2 values. The primary aim of this study was to compare the potential healing prognosis of TcPO2 differentiated for diabetic foot ulcers in different angiosome locations.

METHODS

a 2-years observational cohort prospective study was performed in 81 patients with diabetic foot ulcers. Transcutaneous oxygen pressure measurements were performed at baseline by placing the electrode on two different angiosomes: dorsal zone of the foot (dorsalis pedis angiosome) and between the navicular bone and the tibial malleolus (posterior tibial angiosome). The main outcome was establishing the effectiveness of TcPO2 measurements (dorsalis pedis angiosome and posterior tibial angiosome) for predicting DFU healing.

RESULTS

Transcutaneous oxygen pressure probe placed in the dorsum of the foot (dorsalis pedis angiosome) yielded a sensitivity (S) of 95 % and specificity (SP) of 73 %, and an area under the curve (AUC) of 0.902 (p < 0.001 [0.84-0.96]) for ulcers located in the forefoot and toes; while TcPO2 placed in the posterior tibial angiosome yielded an S of 100 % and SP of 85 % and an AUC of 0.894 (p < 0.001 [0-822-0.966]) for DFU located in the midfoot and heel.

CONCLUSION

This study suggests that angiosome-guided TcPO2 contributes to a prognosis of successful foot ulcer healing.

Relationship Between Diabetes-Related Large-Fiber Neuropathy and Dorsiflexion Range of Motion at the Ankle and First Metatarsophalangeal Joints

BACKGROUND

Diabetes-related peripheral neuropathy (DPN) and limited joint mobility of the foot and ankle are implicated in the development of increased plantar pressures and diabetes-related foot ulcers. The extent of this relationship has not been conclusively established. We aimed to determine the relationship between ankle joint and first metatarsophalangeal joint dorsiflexion range of motion and DPN using a cross-sectional observational study design.

METHODS

Primary outcomes were DPN status, ankle joint range of motion (extended and flexed knee lunge tests), and nonweightbearing first metatarsophalangeal joint range of motion. Correlations were performed using Pearson r, and hierarchical regression analyses were undertaken to determine the independent contribution of DPN to the variance in dorsiflexion range of motion of ankle and first metatarsophalangeal joints using standardized β regression coefficients, controlling for age, sex, body mass index, diabetes duration, and hemoglobin A1c level.

RESULTS

One hundred one community-dwelling participants (mean ± SD age, 65.0 ± 11.2 years; 55 men; 97% type 2 diabetes; mean ± SD diabetes duration, 8.7 ± 7.8 years; 23% with DPN) were recruited. Diabetes-related peripheral neuropathy demonstrated significant correlations with reduced range of motion at the ankle joint (knee extended: r = -0.53; P < .001 and knee flexed: r = -0.50; P < .001) and the first metatarsophalangeal joint (r = -0.37; P < .001). Also, DPN made significant, unique contributions to the regression models for range of motion at the ankle joint (knee extended: r2 change = 0.121; β = -0.48; P < .001 and knee flexed: r2 change = 0.109; β = -0.45; P < .001) and first metatarsophalangeal joint (r2 change = 0.037; β = -0.26; P = .048).

CONCLUSIONS

These findings suggest that DPN contributes to reduced ankle and first metatarsophalangeal joint range of motion. Due to the established link between reduced ankle and first metatarsophalangeal joint range of motion and risk of diabetes-related foot ulcer, we recommend that clinicians assess dorsiflexion range of motion at these joints as part of routine foot assessment in people with diabetes, especially those with DPN. Globally, approximately 436 million adults aged 20 to 79 years are living with diabetes.1 Diabetes is the leading cause of lower-limb amputation and is associated with a lifetime incidence of diabetes-related foot ulcer (DFU) of up to 34%.2 Diabetes-related peripheral neuropathy (DPN) affects approximately 30% to 50% of people with diabetes3 and is one of the most significant risk factors for the development of DFU and amputation.4 Diabetes-related peripheral neuropathy occurs as a result of neural ischemia and perineural edema causing neural demyelination, affecting nerve conductivity.5 In the presence of DPN, intrinsic foot muscle wasting can lead to the development of foot deformities such as digital clawing, which, when coupled with structural and functional changes to the skin, make it less resistant to shear forces and further increase plantar pressure and risk of DFU.6,7.

Wearable sensors-based postural analysis and fall risk assessment among patients with diabetic foot neuropathy

AIMS

To investigate the cross-sectional association between deep and superficial diabetic neuropathy, postural impairment assessed by wearable inertial sensors, and the risk of fall among patients with diabetic foot.

METHODS

Diabetic patients attending a University Podiatric Clinic were evaluated for the presence of deep and superficial peripheral neuropathy in sensory tests. Postural impairment was assessed using a wearable inertial sensor, and the evaluation of balance/gait and risk of fall was determined by the Tinetti Scale and Downton Index, respectively. Glycemic control was measured by glycated haemoglobin concentration and fasting glycaemia. The postural parameters measured were the anteroposterior and medio-lateral sway of the center of mass (CoM) and the sway area (area traveled by the CoM per second). The results were analyzed through a logistic regression model to assess those posture variables mostly significantly associated with neuropathy and risk of fall scales.

RESULTS

A total of 85 patients were evaluated. Spearman's rank correlation coefficients showed a strong and significant relationship (p < 0.05) between deep diabetic neuropathy assessed by Semmes-Weinstein monofilament, diapason and biothensiometer and postural alterations, whereas no significant correlations between superficial (painful sensitivity) neuropathy and the postural parameters. The sway path of the displacement along the anterior-posterior axis recorded during tests performed with eyes open and feet close together were significantly (p < 0.05) correlated with a poor glycemic (glycated haemoglobin concentration) control and each other with all diabetic neuropathy tests, fall risk scales, muscular weakness, ankle joint limitation and history of ulcers.

CONCLUSIONS

The results support the existence of a strong association between alterations of the deep somato-sensitive pathway (although depending on the tool used to measure peripheral neuropathy), glycemic control and balance impairments assessed using a wearable sensors. Wearable-based postural analysis might be part of the clinical assessment that enables the detection of balance impairments and the risk of fall in diabetic patients with diabetic peripheral neuropathy.

Clinical outcomes of selective plantar fascia release for hallux interphalangeal joint ulcers

BACKGROUND

Plantar hallux IPJ ulcers are common and challenging to manage, with many available treatments. One newer technique called SPFR has been used in the management of plantar forefoot ulcers.

OBJECTIVE

This case series reports the clinical results of SPFR for treatment of strictly plantar hallux IPJ ulcers.

MATERIALS AND METHODS

A retrospective chart review was conducted on patients that underwent SPFR procedure by a single foot and ankle surgeon from 2018 to 2023. The primary study outcome was to identify the rate and time of healing associated with SPFR for hallux IPJ ulcers. Only the initial surgery was evaluated for time of healing for the ulcer, healing rate, and complications. Subsequent surgeries were reviewed as well. Patient charts were further reviewed to determine the presence or absence of a postoperative complication.

RESULTS

A total of 17 feet from 17 patients were studied. The hallux IPJ ulcers healed in an average of 3.0 months. The average follow-up time was 26.9 months. Fifteen patients (88.2%) healed after the SPFR procedure. Five patients (29.4%) developed transfer lesions, and 7 patients (41.2%) developed postoperative complications.

CONCLUSIONS

The authors believe that SPFR can be utilized in the treatment of hallux IPJ ulcers if both surgeons and patients are aware of the potential complications and limitations of this procedure. Further research is warranted to evaluate the efficacy and reproducibility of these results.

Mobile Application for Adhering to Diabetic Foot Self-care: Randomized Controlled Clinical Trial

This study aimed to analyze the effectiveness of a mobile application for adherence to foot self-care in people with type 2 diabetes at risk for diabetic foot ulcer. A double-blind randomized controlled clinical trial was conducted with people with type 2 diabetes in a secondary healthcare unit. A total of 42 patients were recruited, matched, and allocated into two groups: one (intervention group) undergoing standard nursing consultations and application use and the other (control group) receiving only standard nursing consultations. The outcome variable was the adherence to foot self-care, measured by completing questionnaires on diabetes self-care activities and adherence to foot self-care. Measures of central tendency and dispersion were calculated, in addition to bivariate associations, considering a significance level of P ≤ .05. The intragroup and intergroup analyses regarding diabetes self-care did not show statistical significance; however, the intervention group showed a considerable increase in the frequency of daily assessments ( P = .048) and adherence to foot self-care ( P = .046). The use of the app, combined with the nursing consultation, increased adherence to foot self-care of people with type 2 diabetes. Brazilian Registry of Clinical Trials: U1111-1202-6318.

Lower serum branched-chain amino acid catabolic intermediates are predictive signatures specific to patients with diabetic foot

Diabetic foot (DF) is one of the serious chronic complications of diabetes. Accurate prediction of the risk of DF may take timely intervention measures to prevent its occurrence. The understanding of metabolomic changes in the progression of diabetes to DF may reveal new targets for interventions. We hypothesized that changes in metabolic pathways during DF would lead to changes in the metabolic profile, which could be predictive signature specific to it. In the present study, 43 participants with type 2 diabetes mellitus (T2DM), 32 T2DM participants with DF (T2DM-F), and 36 healthy subjects were enrolled and their serum samples were used for targeted and nonpolar metabolic analysis with liquid chromatography-tandem mass spectrometry. Differential metabolites related to T2DM-F were discovered in metabolomic analysis. Lasso machine learning regression model, random forest algorithm, causal mediation analysis, disease risk assessment, and clinical decision model were carried out. T2DM and T2DM-F groups could be distinguished with the healthy control group. The differential metabolites were all enriched in alpha-linolenic acid and linoleic acid metabolic pathways including arachidonic acid, docosapentaenoic-acid 22N-6, and docosahexaenoic-acid, which were significantly lower in the T2DM and T2DM-F groups compared with the healthy control group. The differential metabolites in T2DM-F vs T2DM groups were enriched to branched-chain amino acid (BCAA) catabolic pathways involving in methylmalonic acid, succinic acid, 3-methyl-2-oxovaleric acid, and ketoleucine, which were the BCAA catabolic intermediates and significantly lower in the T2DM-F compared with the T2DM group except for succinic acid. We reveal a new set of predictive signatures and associate the lower BCAA catabolic intermediates with the progression from T2DM to T2DM-F.

The Validity and Reliability of the SINBAD Classification System for Diabetic Foot Ulcers

ABSTRACT

Diabetic foot ulcers (DFUs) are a serious and costly complication of diabetes mellitus with a global prevalence of 6.3% and cost of £8,800 per unhealed DFU in the National Health Service. The three main types of DFU are neuropathic, ischemic, and neuroischemic, with an estimated prevalence of 35%, 15%, and 50%, respectively. Because 85% of lower-limb amputations in patients with diabetes are preceded by a DFU, the task of reducing the current and future burden of DFUs on an international level is of crucial importance. Classification of a DFU is an important and complex process with many independent variables that influence the wound severity. Correct classification of a DFU is important to prevent deterioration in the short term and lower-limb amputation in the long term. Both the accuracy of the clinician's interpretation of categorical data from a classification model and grasp of contextual risk factors can refine diagnoses. The term SINBAD is an acronym for six independent variables: site, ischemia, neuropathy, bacterial infection, area, and depth. This system uses comprehensive parameters with strict criteria to facilitate quick and accurate clinical decisions to prevent lower-limb amputation. In addition to providing quantitative measurement, SINBAD also spotlights the multifaceted characteristics of DFUs. By evaluating the validity and reliability of the SINBAD classification system, its applicability for the assessment of DFUs and prevention of lower-limb amputation can be better understood.

Combination of Shengji ointment and bromelain in the treatment of exposed tendons in diabetic foot ulcers: study protocol for a non-blind, randomized, positive control clinical trial

BACKGROUND

Diabetic foot ulcers often affect tendon tissue. Consequently, the infection may spread proximally along the tendon, leading to amputation or even the death of patients. Exposed, degenerated, and necrotic tendons are key factors affecting the healing of diabetic foot ulcers. The effective treatment of the tendon involvement may positively affect the prognosis. In clinical practice, treatment with Shengji ointment and bromelain induces islands of granulation tissue on the denatured tendon surface, which gradually grows and merges. Ideally, the exposed tendon is covered entirely by granulation tissue. This trial aims to assess the effect of a combined treatment regime of Shengji ointment, which has been shown to regenerate muscle tissue and pineapple protease in preventing the loss of function and amputation caused by tendon necrosis. This trial will provide high-quality evidence for the effectiveness of this combination in healing diabetic ulcers with tendon necrosis.

METHODS

The sample size will be 180 patients who will be randomly assigned 1:1 to a treatment group (90 patients) using Shengji ointment combined with bromelain and a control group (90 patients) using hydrocolloid dressing. Both groups will continue their conventional treatments, such as blood glucose and blood pressure medication, lipid regulation, antiplatelets, and others. The primary outcome will be the wound coverage with granulation tissue. Secondary outcomes will be the wound healing rate, amputation extent (where needed), time to granulation, and the Maryland Foot Score. Other efficacy outcomes will be the time to debridement of necrotic tendon tissue and granulation tissue score.

DISCUSSION

This study will treat patients with diabetic foot ulcers with exposed, degenerated, and necrotic tendons with Shengji ointment and bromelain. The trial aims to promote regeneration and healing, to preserve the limb and its function, and to develop a comprehensive and effective protocol that can be applied to promote the healing of exposed tendons in diabetic foot wounds.

TRIAL REGISTRATION

ChiCTR2000039327 ; date of registration: 2020-10-23.

Community-associated methicillin-resistant Staphylococcus aureus infection of diabetic foot ulcers in an eastern diabetic foot center in a tertiary hospital in China: a retrospective study

BACKGROUND

Diabetic foot concerns are a major public health problem. Methicillin-resistant Staphylococcus aureus (MRSA) plays a significant role in diabetic foot ulcers. Community-associated MRSA has become notorious for skin and skin soft tissue infections over the last two decades. This study investigated MRSA infection in diabetic foot patients at a tertiary hospital, focusing on the epidemiology and characteristics of community-associated MRSA.

METHODS

A total of 149 patients with diabetic foot infection whose culture results indicated Staphylococcus aureus as the source were selected. Epidemiological investigations, clinical characteristics, laboratory index records, antibiotic susceptibility analysis, and clinical outcome tracking were performed in all cases. Based on oxacillin resistance using the Vitek Compact 2 system, cases were divided into methicillin-sensitive Staphylococcus aureus and MRSA groups. Subgroup analysis of the MRSA group was performed in accordance with the Centers for Disease Control definition: community-associated MRSA and hospital-associated MRSA.

RESULTS

The MRSA group (n = 41, 27.5%) had a longer duration of ulcers and hospital stay and higher hospitalization costs than the methicillin-sensitive Staphylococcus aureus group (n = 108, 72.5%). According to the classification criteria of Infectious Diseases Society of America, the severity of infection in the community-associated MRSA group was higher than that in the hospital-associated MRSA group. The analysis of antimicrobial susceptibility of 41 MRSA isolates showed that the resistance rates to erythromycin, clindamycin, quinolone, gentamicin, tetracycline, and rifampicin were 78.0%, 68.3%, 31.7%, 17.1%, 9.8%, and 2.4%, respectively. All the MRSA strains were sensitive to linezolid, tigecycline, and vancomycin. The resistance rates to quinolones and gentamycin in the community-associated MRSA group (both 0%) were lower than those in the hospital-associated MRSA group.

CONCLUSION

Emergence of MRSA in diabetic foot ulcer was associated with a prolonged wound duration and increased consumption of medical resources. Community-associated MRSA strains predominated among MRSA isolates from diabetic foot wounds and caused more severe infections.

The impact of wound pH on the antibacterial properties of Medical Grade Honey when applied to bacterial isolates present in common foot and ankle wounds. An in vitro study

BACKGROUND

Diabetic foot ulcers (DFUs) and post-surgical wound infections are amongst the most troublesome complications of diabetes and following foot and ankle surgery (FAS) respectively. Both have significant psychosocial and financial burden for both patients and the healthcare system. FAS has been reported to have higher than average post-surgical infections when compared to other orthopaedic subspecialties. Evidence also indicates that patients with diabetes and other co morbidities undergoing FAS are at a much greater risk of developing surgical site infections (SSIs). With the growing challenges of antibiotic resistance and the increasingly high numbers of resilient bacteria to said antibiotics, the need for alternative antimicrobial therapies has become critical.

AIM

The aim of this study was to investigate the use of medical grade honey (MGH) when altered to environments typically present in foot and ankle wounds including DFUs and post-surgical wounds (pH6-8).

METHODS

MGH (Activon) was altered to pH 6, 7 and 8 and experimental inoculums of Pseudomonas aeruginosa (NCTC10782), Escherichia coli, (NCTC10418), Staphylococcus aureus (NCTC10655) and Staphylococcus epidermidis (NCTC 5955) were transferred into each pH adjusted MGH and TSB solution and the positive and negative controls.

RESULTS

MGH adjusted to various pH values had the ability to reduce bacteria cell survival in all pH variations for all bacteria tested, with the most bacterial reduction/elimination noted for Staphylococcus epidermidis. No correlations were noted among the pH environments investigated and the colony counts, for which there were small amounts of bacteria survived.

CONCLUSION

This research would indicate that the antibacterial properties of honey remains the same regardless of the pH environment. MGH could therefore potentially be considered for use on non-infected foot and ankle wounds to reduce the bacterial bioburden, the risk of infections and ultimately to improve healing outcomes.

Reduction in the prevalence of methicillin-resistant Staphylococcus aureus in tissue and wound swab samples taken from outpatients attending a specialist diabetic foot clinic 2005-2021

AIMS

To assess annual change in prevalence of methicillin resistant Staphylococcus aureus (MRSA) from tissue and wound swab samples from foot ulcers (DFUs) in people with diabetes between 2005 and 2021.

METHODS

A retrospective analysis of everyone with MRSA positive wound or tissue swabs taken from our specialist multidisciplinary foot clinic between July 2005 and July 2021.

RESULTS

A total of 406 MRSA positive isolates from DFU swabs were identified from 185 individuals attending the foot clinic. There were 22 hospital-acquired infections (HAIs) and 159 community-acquired infections (CAIs). Fifty-two per cent (n = 37) of these individuals from 2010 to 2021 (n = 71) had presence of at least three risk factors for MRSA. The total number of swabs sent was 6312 from 1916 individuals living with diabetes. Annual MRSA DFU prevalence peaked in 2008 at 14.6% (n = 38), decreased in 2013 to 5.2% (n = 20) and did not exceed 4% (n = 6) from 2015 to 2021. Hospital MRSA was lowest in 2021 (n = 211), a 76% fall from 2007 (n = 880). Incidence of MRSA HAI from 2015 to 2021 ranged from 5.4% (n = 14) in 2020 to 11.5% (n = 41) in 2018.

CONCLUSIONS

Prevalence of MRSA in DFU infections treated as outpatients is decreasing in line with falls in hospital acquired blood-borne infections and with overall hospital MRSA incidence. This is likely a reflection of the combination of interventions, including stringent antibiotic prescribing and decolonisation strategies. Reduction in prevalence should have positive impact on outcomes in people living with diabetes, reducing the complication of osteomyelitis and necessity for long-term antibiotic administration.

Evaluation of risk factors for foot ulceration in individuals with chronic kidney disease

INTRODUCTION

CKD, like DM, is an independent risk factor for the development and course of foot ulcers.

OBJECTIVE

The authors studied the incidence and risk factors of foot ulceration in patients with CKD and with or without DM and in patients receiving or not receiving HD.

MATERIALS AND METHODS

Patients with or without DM and with renal failure were divided into 4 groups of 40 patients each according to whether or not they were receiving HD. Data were collected using a patient information form, physical examination of the foot, and risk assessment forms.

RESULTS

Lower extremity ulceration was highest in group 3 (HD+DM+) (15% [6 of 40]), that is, in patients with CKD and DM receiving HD (P = .421). Patients in group 3 were at highest risk for foot ulcers (72.5%) compared with other groups (P = .001). Risk factors associated with foot ulceration were advanced stage (ie, stage 4 or 5) CKD, HD treatment, age, BMI, history of lower extremity ulceration and/or amputation, foot deformities, skin and nail pathology, neuropathy, and vascular insufficiency.

CONCLUSIONS

Patients with CKD receiving HD are at high risk for foot ulcers, and this risk increases with the presence of DM.

Physical therapy in diabetic foot ulcer: Research progress and clinical application

Diabetes foot ulcer (DFU) is one of the most intractable complications of diabetes and is related to a number of risk factors. DFU therapy is difficult and involves long-term interdisciplinary collaboration, causing patients physical and emotional pain and increasing medical costs. With a rising number of diabetes patients, it is vital to figure out the causes and treatment techniques of DFU in a precise and complete manner, which will assist alleviate patients' suffering and decrease excessive medical expenditure. Here, we summarised the characteristics and progress of the physical therapy methods for the DFU, emphasised the important role of appropriate exercise and nutritional supplementation in the treatment of DFU, and discussed the application prospects of non-traditional physical therapy such as electrical stimulation (ES), and photobiomodulation therapy (PBMT) in the treatment of DFU based on clinical experimental records in ClinicalTrials.gov.

Residual osteomyelitis at the resection margin after conservative surgery is not associated with the recurrence of diabetic foot infection and may successfully be treated without postoperative antibiotic therapy

AIMS

We hypothesize that microbiology- and pathology-confirmed positive bone margins after the resection of diabetes-related foot osteomyelitis are associated with worse outcomes.

METHODS

We conducted a prospective study consisting of a cohort of 93 patients with diabetes-related foot osteomyelitis (histopathology confirmed) who underwent bone resection and where an additional bone biopsy was taken at the resection margin. The primary outcome was the recurrence of the infection.

RESULTS

Pathology-confirmed positive margins were detected in 62 cases (66.7%), microbiology-confirmed positive margins were detected in 75 cases (80.6%) and recurrence was detected in 19 patients (20.4%). Chi-squared test failed to show the presence of an association between the recurrence of the infection with pathology-confirmed positive margins (p = 0.82), with microbiology-confirmed positive margins, (p = 0.34) and with the use of postoperative antibiotics (p = 0.70). Healing in patients with pathology-confirmed positive margins was achieved in a median of 12 weeks (95% CI 9.2-18) and those with pathology-confirmed negative margins in 14.9 weeks (95% CI 10.2-21.9), Log-rank test, p = 0.74. Thirty-four patients out of 61 available for follow-up (55.7%) with pathology-confirmed positive margins were treated without postoperative antibiotics. In that group, Chi-squared test failed to show the presence of an association between the recurrence of the infection with the use of postoperative antibiotics (p = 0.47).

CONCLUSIONS

A positive margin was neither associated with the recurrence of the infection nor with the time to healing. More than half of patients with pathology-confirmed positive margins were treated without postoperative antibiotics and this approach was not associated with the recurrence of the infection.

Off-loading and compression therapy strategies to treat diabetic foot ulcers complicated by lower limb oedema: a scoping review

BACKGROUND

Lower limb oedema is a common co-morbidity in those with diabetes and foot ulceration and is linked with increased amputation risk. There is no current guidance for the treatment of concurrent diabetic foot ulcers and lower limb oedema, leading to uncertainty around the safety and efficacy of combination approaches incorporating offloading and compression therapies. To determine indications and contraindications for such strategies and identify any other supplementary treatment approaches, a scoping review was undertaken to map the evidence relating to off-loading and compression therapy strategies to treat both diabetic foot ulcers and lower limb oedema in combination.

METHODS

Following the Joanna Briggs Institute (JBI) and PRISMA - Scoping Review (ScR) guidance, this review included published and unpublished literature from inception to April 2022. Literature was sourced using electronic databases including Cochrane Library, PubMed, CINAHL, AMED; websites; professional journals and reference lists of included literature. Eligible literature discussed the management of both diabetic foot ulceration and lower limb oedema and included at least one of the treatment strategies of interest. Data extraction involved recording any suggested off-loading, compression therapy or supplementary treatment strategies and any suggested indications, contraindications and cautions for their use.

RESULTS

Five hundred twenty-two publications were found relating to the management of diabetic foot ulcers with an off-loading strategy or the management of lower limb oedema with compression therapy. 51 publications were eligible for inclusion in the review. The majority of the excluded publications did not discuss the situation where diabetic foot ulceration and lower limb oedema present concurrently.

CONCLUSIONS

Most literature, focused on oedema management with compression therapy to conclude that compression therapy should be avoided in the presence of severe peripheral arterial disease. Less literature was found regarding off-loading strategies, but it was recommended that knee-high devices should be used with caution when off-loading diabetic foot ulcers in those with lower limb oedema. Treatment options to manage both conditions concurrently was identified as a research gap. Integrated working between specialist healthcare teams, was the supplementary strategy most frequently recommended. In the absence of a definitive treatment solution, clinicians are encouraged to use clinical reasoning along with support from specialist peers to establish the best, individualised treatment approach for their patients.

TRIAL REGISTRATION

Open Science Framework (osf.io/crb78).

Electrodermal activity and heart rate variability for detection of peripheral abnormalities in type 2 diabetes: A review

Modern medicine exhibits an upward trend towards non-invasive methods for early detection of disease and long-term monitoring of patients' health. Diabetes mellitus and its complications are a promising area for implementation of new medical diagnostic devices. One of the most serious complications of diabetes is diabetic foot ulcer. The main causes responsible for diabetic foot ulcer are ischemia caused by peripheral artery disease and diabetic neuropathy caused by polyol pathway-induced oxidative stress. Autonomic neuropathy impairs function of sweat glands, which can be measured by electrodermal activity. On the other hand, autonomic neuropathy leads to changes in heart rate variability, which is used to assess autonomic regulation of the sinoatrial node. Both methods are enough sensitive to detect pathological changes caused by autonomic neuropathy and are promising screening methods for early diagnosis of diabetic neuropathy, which could prevent the onset of diabetic ulcer.

Is the duration of diabetic foot ulcers an independent risk factor for developing diabetic foot osteomyelitis?

OBJECTIVE

This study aimed to determine whether the prolonged duration of diabetic foot ulcers was associated with an increased incidence of diabetic foot osteomyelitis.

STUDY DESIGN

A retrospective cohort study METHODS: The medical records of all patients who participated in the diabetic foot clinic between January 2015 and December 2020 were reviewed. Patients with new diabetic foot ulcers were monitored for diabetic foot osteomyelitis. The collected data included the patient's profile, comorbidities and complications, the ulcer profile (area, depth, location, duration, number of ulcers, inflammation, and history of the previous ulcer), and outcome. Univariate and multivariate Poisson regression analyses were used to assess risk variables for diabetic foot osteomyelitis.

RESULTS

Eight hundred and fifty-five patients were enrolled; 78 developed diabetic foot ulcers (cumulative incidence 9% over 6 years, average annual incidence 1.5%) and among these diabetic foot ulcers, 24 developed diabetic foot osteomyelitis (cumulative incidence 30% over 6 years, average annual incidence of 5%, incidence rate 0.1/person-year). Statistically significant risk factors for the development of diabetic foot osteomyelitis were ulcers that were deep to the bone (adjusted risk ratio 2.50, p = 0.04) and inflamed wounds (adjusted risk ratio 6.20, p = 0.02). The duration of diabetic foot ulcers was not associated with diabetic foot osteomyelitis (adjusted risk ratio 1.00, p = 0.98).

CONCLUSION

The duration was not an associated risk factor for diabetic foot osteomyelitis, while bone-deep ulcers and inflamed ulcers were found to be significant risk factors for the development of diabetic foot osteomyelitis.

Percutaneous Partial Bone Excision in the Management of Diabetic Toe Osteomyelitis

BACKGROUND

Diabetic foot osteomyelitis affecting the toes is associated with several complications including amputation. Management is variable and include medical therapy alone or coupled with surgery. Removal of infected tissues is a common therapeutic option. However, limited source data are available. This study determines the outcome and complications of percutaneous partial bone excision (PPBE) of infected bone among diabetic patients with toe osteomyelitis.

METHODS

This is an uncontrolled experimental prospective study in diabetic patients who underwent PPBE of infected pieces of bone for toe osteomyelitis in the outpatient setting at a single foot clinic. All participants were followed up until the occurrence of wound healing or amputation.

RESULTS

Forty-seven patients (mean ± SD age was 62.8 ± 11.6 years) participated. Forty-four patients (93.6%) had complete healing and 3 (6.4%) required toe amputation. The mean (±SD) wound healing time was 11 (±4.6) (range, 7-22) weeks. Diabetes mellitus type 1 and younger age were significantly associated with increased risk for amputation.

CONCLUSION

PPBE of infected toes in diabetic patients can be performed successfully and safely in the outpatient clinic. It can also improve healing and avoids inpatient stay.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Diverse Antibacterial Treatments beyond Antibiotics for Diabetic Foot Ulcer Therapy

Diabetic foot ulcer (DFU), a common complication of diabetes, has become a great burden to both patients and the society. The delayed wound closure of ulcer sites resulting from vascular damage and neutrophil dysfunction facilitates bacterial infection. Once drug resistance occurs or bacterial biofilm is formed, conventional therapy tends to fail and amputation is unavoidable. Therefore, effective antibacterial treatment beyond antibiotics is of utmost importance to accelerate the wound healing process and prevent amputation. Considering the complexity of multidrug resistance, biofilm formation, and special microenvironments (such as hyperglycemia, hypoxia, and abnormal pH value) at the infected site of DFU, several antibacterial agents and different mechanisms have been explored to achieve the desired outcome. The present review focuses on the recent progress of antibacterial treatments, including metal-based medications, natural and synthesized antimicrobial peptides, antibacterial polymers, and sensitizer-based therapy. This review provides a valuable reference for the innovation of antibacterial material design for DFU therapy.

Elevated HbA1c level associated with disease severity and surgical extension in diabetic foot patients

BACKGROUND

Diabetic foot is a complex syndrome that is associated with other diabetic complications, such as peripheral arte-rial disease and peripheral neuropathy. Optimization of plasma glucose and glycated hemoglobin (HbA1c) is one of the main principles of standard care and treatment approaches in individuals with diabetes mellitus (DM). In this study, the relationship of HbA1c level at the time of diagnosis was evaluated with diabetic foot disease severity score and surgical extension in patients with Type 2 DM.

METHODS

This study included 301 consecutive patients who were diagnosed with diabetic foot in the general surgery diabetic foot clinic and were hospitalized for surgery. The relationships between the HbA1c levels of the patients with the Wagner and PEDIS (Perfusion, Extent, Dept, Infection, Sensation) classification system grades, and the surgical procedures performed were analyzed and the treatment outcomes were evaluated.

RESULTS

It was determined that there was a 90% statistically significant relationship between HbA1c values of ≥10.1% and the de-velopment of Wagner Grade 4 diabetic foot ulcer (DFU) (P=0.037). A strong statistically significant relationship at the rate of 85% was determined between HbA1c values of ≥10.1% and the development of PEDIS Grade 3 ulcers. As the HbA1c values increased, so there was determined to be a statistically significant relationship with the development of PEDIS Grade 3 ulcer (P=0.003). In the comparison of the HbA1c values according to the type of surgery performed, a weak relationship was determined at the rate of 26%, and it was determined that as the HbA1c values increased, so there could be an increase in the amputation level.

CONCLUSION

The results of this study showed that as HbA1c values at diagnosis increased in patients with diabetic foot; Wagner/PEDIS grades, disease severity, surgical extension, amputation level, and tissue loss increased. To reduce the severity of diabetic foot disease and prevent amputation, compliance with diabetic treatment and glycemic control should be increased.

Prevalence of Peripheral Arterial Disease in Diabetic Foot Ulcer Patients and its Impact in Limb Salvage

Diabetic foot ulcer syndrome is a common complication of diabetes mellitus. Three main factors contribute to it: neuropathy, vasculopathy, and infection. This study was conducted to evaluate the prevalence of peripheral arterial disease (PAD) in diabetic foot ulcer patients and its impact on limb salvage as an outcome. This prospective cross-sectional study included 392 cases, who were divided according to the presence of PAD into 2 groups; patients with PAD were labeled as PAD +ve (172 cases) and those without PAD were labeled as PAD -ve (22 cases). All cases were clinically assessed, and routine laboratory examinations were ordered. Moreover, duplex ultrasound was done for suspected cases of having PAD by examination. Computed tomography angiography was ordered for patients who are in need of a revascularization procedure. Cases were managed by debridement and/or revascularization. After that, these cases were assessed clinically and radiologically for vascularity and infection and the possibility for amputation was evaluated. Infection was classified using Wagner Classification System, and revascularization was decided according to the TASC II system. The incidence of PAD in cases with diabetic foot ulcer syndrome was 43.87%. No difference was detected between the 2 groups regarding age and gender (P > .05). The prevalence of smoking, hemodialysis, ischemic heart disease (IHD), and hypertension was more significantly higher in cases with PAD (P < .05). Revascularization procedures were only performed in cases that had documented severe PAD or chronic limb-threatening ischemia in addition to foot ulcer and/or infection. With regard to limb salvage, it was more significantly performed in cases without PAD (82.3% vs 48.3% in PAD cases; P < .001). Male gender, smoking, ankle-brachial pressure index, hemodialysis, IHD, neuropathy, HbA1C, PAD, and high Wagner classification were predictors of limb amputation (P < .05). PAD is associated with worse outcomes in diabetic foot ulcer patients. Not only does it constitute a great number among diabetic foot ulcer patients, but it also has a negative impact on limb salvage.

Diabetic foot and lower limb amputations at central, provincial and tertiary hospitals-underscores the need for organised foot health services at primary healthcare level

BACKGROUND

Diabetic foot amputations are a devastating outcome for any diabetic patient. They are associated with various risk factors, including failure to risk stratify the diabetic foot. Early risk stratification could lower foot complications risk at the primary healthcare level (PHC). In the Republic of South Africa (RSA), PHC clinics are the first entry point to the public healthcare system. Failure to correctly identify, risk categorise, and refer diabetic foot complications at this level may lead to poor clinical outcomes for diabetic patients. This study looks at the incidence of diabetic-related amputations at central and tertiary hospitals in Gauteng to highlight the case of the needed foot health services at the PHC level.

METHODS

A cross-sectional retrospective study that reviewed prospectively collected theatre records database of all patients who underwent a diabetic-related foot and lower limb amputation between January 2017 and June 2019. Inferential and descriptive statistics were performed, and patient demographics, risk factors and type of amputation were reviewed.

RESULTS

There were 1862 diabetic-related amputations in the period under review. Most patients (98 %) came from a poor socioeconomic background earning ZAR 0.00-70 000.00 (USD 0.00-4754.41) per annum. Most amputations, 62 % were in males, and the majority, 71 % of amputations, were in patients younger than 65. The first amputation was major in 73 % of the cases, and an infected foot ulcer was a primary amputation cause in 75 % of patients.

CONCLUSION

Amputations are a sign of poor clinical outcomes for diabetic patients. Due to the hierarchal nature of healthcare delivery in RSA, diabetic-related foot amputations could imply inadequate care of or access to diabetic foot complications at the PHC level in RSA. A lack of access to structured foot health services at PHC levels impedes early identification of foot complication identification and appropriate referral resulting in amputation in some of the patients.

Real-world treatment patterns and diagnosis of charcot foot in franco-belgian diabetic foot expert centers (The EPiChar Study)

AIM

To evaluate the real-life diagnosis and therapeutic means of Charcot Neuroosteoarthropathy (CN) in French-Belgian diabetic foot expert centers.

METHODS

We collected clinical characteristics, results of exams and therapeutic pathways of consecutive adult patients with diabetic osteoarthropathy seen in consultation or hospitalization from January 1 to December 31, 2019 in 31 diabetic foot expert centers. The primary outcome was to describe the diagnostic and management methods for CN according to patient clinical characteristics, the clinical-radiological characteristics of acute and chronic CN and discharge means.

RESULTS

467 patients were included: 364 with chronic CN and 103 in the acute phase. 101 patients had bilateral chronic CN. Most patients were male (73.4%), treated with insulin (73.3%), and with multicomplicated diabetes. In the acute phase, edema and increased foot temperature were present in 75% and 58.3% of cases, respectively. Diagnosis confirmation was usually by MRI and the mode of discharge was variable. In the chronic phase, orthopedic shoes were prescribed in 81.5% of cases.

CONCLUSIONS

This observational study highlights the diagnostic and therapeutic practices in 31 diabetic foot centers. Our results highlight that the use of MRI and the modalities of offloading, an essential treatment in the acute phase, need to be better standardized. Centers were highly encouraging about creating a patient registry.

Preliminary evaluation of dual-energy CT to quantitatively assess bone marrow edema in patients with diabetic foot ulcers and suspected osteomyelitis

OBJECTIVES

The purpose of this study is to evaluate the value of dual-energy CT (DECT) with virtual non-calcium (VNCa) in quantitatively assessing the presence of bone marrow edema (BME) in patients with diabetic foot ulcers and suspected osteomyelitis.

METHODS

Patients with a diabetic foot ulcer and suspected osteomyelitis that underwent DECT (80 kVp/Sn150 kVp) with VNCa were retrospectively included. Two observers independently measured CT values of the bone adjacent to the ulcer and a reference bone not related to the ulcer. The patients were divided into two clinical groups, osteomyelitis or no-osteomyelitis, based on the final diagnosis by the treating physicians.

RESULTS

A total of 56 foot ulcers were identified of which 23 were included in the osteomyelitis group. The mean CT value at the ulcer location was significantly higher in the osteomyelitis group (- 17.23 ± 34.96 HU) compared to the no-osteomyelitis group (- 69.34 ± 49.40 HU; p < 0.001). Within the osteomyelitis group, the difference between affected bone and reference bone was statistically significant (p < 0.001), which was not the case in the group without osteomyelitis (p = 0.052). The observer agreement was good for affected bone measurements (ICC = 0.858) and moderate for reference bone measurements (ICC = 0.675). With a cut-off value of - 40.1 HU, sensitivity was 87.0%, specificity was 72.7%, PPV was 69.0%, and NPV was 88.9%.

CONCLUSION

DECT with VNCa has a potential value for quantitatively assessing the presence of BME in patients with diabetic foot ulcers and suspected osteomyelitis.

KEY POINTS

• Dual-energy CT (DECT) with virtual non-calcium (VNCa) is promising for detecting bone marrow edema in the case of diabetic foot ulcers with suspected osteomyelitis. • DECT with VNCa has the potential to become a more practical alternative to MRI in assessing the presence of bone marrow edema in suspected osteomyelitis when radiographs are not sufficient to form a diagnosis.

Salvage percutaneous transluminal angioplasty of the superficial femoral artery in the diabetic foot with deteriorating limb ischemia

INTRODUCTION

PAD frequently co-occurs with diabetes, often leading to chronic nonhealing wounds. Foot gangrene and amputation are common outcomes of untreated CLI.

CASE REPORT

A 67-year-old male with diabetes and deteriorating limb ischemia following surgical stress underwent successful surgical repair after emergency PTA of the SFA for extensive heel necrosis. After surgical debridement of necrotic heel tissue, the ABI on the affected side suddenly reduced to 0.36, but it improved to 1.06 at 4 weeks following stenting angioplasty, allowing the subsequent flap surgery to repair the heel defect. At the 1-year follow-up visit, the patient exhibited durable heel coverage and the restoration of weightbearing function. No signs or symptoms indicative of restenosis were evident in the blood vessel treated with stent angioplasty.

CONCLUSION

This case highlights the importance of proper evaluation of critical ischemic conditions and the need for prompt endovascular interventions in preserving the at-risk diabetic foot.

No Difference in Risk of Amputation or Frequency of Surgical Interventions Between Patients With Diabetic and Nondiabetic Charcot Arthropathy

BACKGROUND

The cause of Charcot neuro-osteoarthropathy (CN) is diabetes in approximately 75% of patients. Most reports on the clinical course and complications of CN focus on diabetic CN, and reports on nondiabetic CN are scarce. No study, to our knowledge, has compared the clinical course of patients initially treated nonoperatively for diabetic and nondiabetic CN.

QUESTIONS/PURPOSES

Among patients with CN, are there differences between patients with diabetes and those without in terms of (1) the frequency of major amputation as ascertained by a competing risks survivorship estimator; (2) the frequency of surgery as ascertained by a competing risks survivorship estimator; (3) frequency of reactivation, as above; or (4) other complications (contralateral CN development or ulcers)?

METHODS

Between January 1, 2006, and December 31, 2018, we treated 199 patients for diabetic CN. Eleven percent (22 of 199) were lost before the minimum study follow-up of 2 years or had incomplete datasets and could not be analyzed, and another 9% (18 of 199) were excluded for other prespecified reasons, leaving 80% (159 of 199) for analysis in this retrospective study at a mean follow-up duration since diagnosis of 6 ± 4 years. During that period, we also treated 78 patients for nondiabetic Charcot arthropathy. Eighteen percent (14 of 78) were lost before the minimum study follow-up and another 5% (four of 78 patients) were excluded for other prespecified reasons, leaving 77% (60 of 78) of patients for analysis here at a mean of 5 ± 3 years. Patients with diabetic CN were younger (59 ± 11 years versus 68 ± 11 years; p < 0.01), more likely to smoke cigarettes (37% [59 of 159] versus 20% [12 of 60]; p = 0.02), and had longer follow-up (6 ± 4 years versus 5 ± 3 years; p = 0.02) than those with nondiabetic CN. Gender, BMI, overall renal failure, dialysis, and presence of peripheral arterial disease did not differ between the groups. Age difference and length of follow-up were not considered disqualifying problems because of the later onset of idiopathic neuropathy and longer available patient follow-up in patients with diabetes, because our program adheres to the follow-up recommendations suggested by the International Working Group on the Diabetic Foot. Treatment was the same in both groups and included serial total-contact casting and restricted weightbearing until CN had resolved. Then, patients subsequently transitioned to orthopaedic footwear. CN reactivation was defined as clinical signs of the recurrence of CN activity and confirmation on MRI. Group-specific risks of the frequencies of major amputation, surgery, and CN reactivation were calculated, accounting for competing events. Group comparisons and confounder analyses were conducted on these data with a Cox regression analysis. Other complications (contralateral CN development and ulcers) are described descriptively to avoid pooling of complications with varying severity, which could be misleading.

RESULTS

The risk of major amputation (defined as an above-ankle amputation), estimated using a competing risks survivorship estimator, was not different between the diabetic CN group and nondiabetic CN group at 10 years (8.8% [95% confidence interval 4.2% to 15%] versus 6.9% [95% CI 0.9% to 22%]; p = 0.4) after controlling for potentially confounding variables such as smoking and peripheral artery disease. The risk of any surgery was no different between the groups as estimated by the survivorship function at 10 years (53% [95% CI 42% to 63%] versus 58% [95% CI 23% to 82%]; p = 0.3), with smoking (hazard ratio 2.4 [95% CI 1.6 to 3.6]) and peripheral artery disease (HR 2.2 [95% CI 1.4 to 3.4]) being associated with diabetic CN. Likewise, there was no between-group difference in CN reactivation at 10 years (16% [95% CI 9% to 23%] versus 11% [95% CI 4.5% to 22%]; p = 0.7) after controlling for potentially confounding variables such as smoking and peripheral artery disease. Contralateral CN occurred in 17% (27 of 159) of patients in the diabetic group and in 10% (six of 60) of those in the nondiabetic group. Ulcers occurred in 74% (117 of 159) of patients in the diabetic group and in 65% (39 of 60) of those in the nondiabetic group.

CONCLUSION

Irrespective of whether the etiology of CN is diabetic or nondiabetic, our results suggest that orthopaedic surgeons should use similar nonsurgical treatments, with total-contact casting until CN activity has resolved, and then proceed with orthopaedic footwear. A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach.

LEVEL OF EVIDENCE

Level III, prognostic study.

Diabetic foot disease and the risk of major clinical outcomes

AIMS

Data on the long-term consequences of diabetic foot disease (DFD) are scarce. We examined the association between DFD and major clinical outcomes in patients with diabetes in the general population.

METHODS

We conducted a prospective cohort analysis of 1,428 participants with diabetes in the Atherosclerosis Risk in Communities Study. DFD and four clinical outcomes (nontraumatic lower-extremity amputation, cardiovascular disease, major fall, and death) were captured through 2018 using administrative data. We used Cox regression models to evaluate the association between incident DFD (modeled as a time-varying exposure) and the subsequent risk of clinical outcomes.

RESULTS

During over two decades of follow-up (1996-1998 to 2018), the cumulative incidence of DFD was 33.3%. Risk factors for DFD included older age, poor glycemic control, long diabetes duration, and prevalent vascular disease (chronic kidney disease, retinopathy, cardiovascular disease). Following incident DFD, the five-year cumulative incidence of major clinical outcomes was 38.9% for mortality, 25.2% for cardiovascular disease, 14.5% for nontraumatic lower-extremity amputation, and 13.2% for major fall. DFD remained associated with all four clinical outcomes after multivariable adjustment, with hazard ratios ranging from 1.5 (cardiovascular disease) to 34.7 (lower-extremity amputation).

CONCLUSIONS

DFD is common and confers substantial risk for major morbidity and mortality.

Evidence of Autoimmune Involvement in the Pathogenesis of Charcot Neuroarthropathy: A Novel Hypothesis with Preliminary Data

Charcot neuroarthropathy is a devastating condition that places patients at risk for poor outcomes. Although the condition was first described in 1703, knowledge of the causative agent(s) has yet to be fully understood. Recent advances in genetic research have helped to identify potential mechanisms and pathways for the enigmatic destruction and deformities that are often associated with the condition; however, alternative pathways have been proposed. For the purpose of this discussion, we will discuss the human leukocyte antigen, which is one of the most researched contributors to autoimmune pathology and, more recently, has been linked to diabetic complications.

Conservative Surgery for Diabetic Foot Osteomyelitis is not Associated With Longer Survival Time Without Recurrence of Foot Ulcer When Compared With Amputation

Conservative surgery of diabetic foot osteomyelitis (DFO) in which bone infection is removed without amputation could minimize the biomechanical changes associated with foot surgery. We hypothesize that patients who undergo conservative surgery will have a longer survival time without recurrence of foot ulcers and further amputations than those who undergo any type of amputation to treat DFO. We assessed a retrospective cohort of 108 patients who underwent surgery for DFO from January 2011 to December 2012. Patients were followed-up until May 2020. Reulceration and reamputation-free survival times were plotted using the Kaplan-Meier method and were calculated from the date of first surgery to recurrence, new amputation, or end of the study. A stratified log rank was used to study differences among groups. Cumulative survival without recurrences at 1, 5, and 8 years was 95%, 36%, and 29%, respectively, in patients who underwent conservative surgery and 95%, 43%, and 30%, respectively, in those undergoing amputation. Cumulative survival without a new amputation at 1, 5, and 8 years was 100%, 80%, and 80%, respectively, in patients who underwent conservative surgery and 98%, 82%, and 69%, respectively, in those undergoing amputation. No differences were found regarding either recurrence (log rank, P = .98) or new amputations (log rank, P = .64). In conclusion, conservative surgery is as safe as amputation to arrest bone infection in the feet of patients with diabetes. Conservative surgery was not associated with a lower rate of recurrence and new amputations than those patients who underwent amputations.

The foot in diabetes - a reminder of an ever-present risk

The term 'diabetic foot disease' (DFD) often signifies the presence of foot ulceration and infection, but one must also be wary of the rarer occurrence of Charcot foot disease. The worldwide prevalence of DFD is 6.3% (95%CI: 5.4-7.3%). Foot complications present a major challenge to both patients and healthcare systems, with increased rates of hospitalisation and an almost trebled 5-year mortality. The Charcot foot often occurs in patients with long-standing diabetes, presenting as an inflamed or swollen foot or ankle, following unrecognised minor trauma. This review focuses on the prevention and early identification of the 'at-risk' foot. DFD is best managed by a multi-disciplinary foot clinic team consisting of podiatrists and healthcare professionals. This ensures a combination of expertise and provision of a multi-faceted evidence-based treatment plan. Current research using endothelial progenitor cells (EPC) and mesenchymal stem cells (MSC) offers a new dimension in wound management.

Impact of microvascular complications on the outcomes of diabetic foot in type 2 diabetic patients with documented peripheral artery disease

PURPOSE

Microvascular disease (MVD) is associated with amputation linked to peripheral artery disease (PAD) in the general population. No study evaluated the impact of diabetic microvascular complications on the outcomes of vascular diabetic foot ulcers (DFU). The aim of the study was to investigate whether retinopathy, nephropathy, and polyneuropathy can predict the outcomes of DFU in type 2 diabetic patients with PAD.

METHODS

Three hundred and thirty-one consecutive patients with vascular DFU were enrolled and followed up for 44.1 ± 23.9 months.

RESULTS

The prevalence of retinopathy was significantly higher in subjects with ulcer persistence (45.2%; p < 0.01), minor amputation (48.9%; p < 0.001), and major amputation (57.9%; p < 0.001) than in healed patients (23.3%), and in non-survivors than in survivors (64.9 versus 20.5%; p < 0.001). The prevalence of nephropathy was significantly greater in subjects with ulcer persistence (83.9%; p < 0.01), minor amputation (86.7%; p < 0.001), and major amputation (94.7%; p < 0.001) than in those with healed DFU (64.4%), and in non-survivors than in survivors (88.3 versus 65.7%; p < 0.001). The prevalence of polyneuropathy was significantly higher in non-survivors than in survivors (76.6 versus 61.0%; p = 0.012). Multivariate analysis showed that absence of retinopathy (OR: 0.451; 95% CI: 0.250-0.815; p < 0.001) and nephropathy (OR: 0.450; 95% CI: 0.212-0.951; p = 0.036) were independently associated with healing. Moreover, retinopathy was a predictor both of minor amputation (OR: 2.291; 95% CI: 1.061-4.949; p = 0.034) and mortality (OR: 5.274; 95% CI: 2.524-11.020; p < 0.001). Polyneuropathy never entered the regression model.

CONCLUSIONS

Diabetic microvascular complications, in particular retinopathy, may predict the outcomes of vascular DFU. Longitudinal studies should confirm this finding.

Apolipoprotein A-IV of diabetic-foot patients upregulates tumor necrosis factor α expression in microfluidic arterial models

Diabetic peripheral arterial atherosclerosis is one of the important characteristics of diabetic foot syndrome. Apolipoprotein (Apo A-IV) participates in various physiological processes, and animal studies have shown that it has roles of anti-atherosclerosis, prevention of platelet aggregation and thrombosis. Apo A-IV glycosylation is closely related to the occurrence and development of diabetic peripheral atherosclerosis. This study aimed to explore the mechanism of diabetic peripheral arterial lesions caused by glycosylated Apo A-IV. Type 2 diabetes mellitus (T2DM) and T2DM with diabetic foot patients (T2DM-F; n = 45, 30) were enrolled in this study, and individuals without diabetes (n = 35) served as normal controls (NC). In T2DM group, serum Apo A-IV content was higher than those in NC and T2DM-F group, as carboxymethyl lysine (CML) glycosylation of Apo A-IV in mixed serum from T2DM-F group was identified to be more significant than those in two other groups. Within a microfluidic arterial chip model, Apo A-IV from T2DM and T2DM-F group significantly increased transcription and protein levels of tumor necrosis factor alpha (TNF-α) in chip arteries, and CML expression was observed in T2DM-F group, which were associated with increased nuclear receptor subfamily 4 group A member 3 (NR4A3) expression. Recombinant human Apo A-IV could reverse the stimulating effect of serum Apo A-IV from T2DM-F group on TNF-α expression, and NR4A3 blocking peptide downregulated TNF-α expression by inhibiting NR4A3 expression. In the chip arteries, Apo A-IV from T2DM and T2DM-F increased TNF-α expression and turn them into a pre-atherosclerotic state, which might be one of the important mechanisms of glycosylated Apo A-IV to induce diabetic peripheral arterial lesions and eventually lead to diabetic foot.

Nagging Pain and Foot Ulcers Can be Treated into Remission

Lower extremity ulcerations are very common in patients with diabetes. These wounds lead to amputation in a surprisingly large percentage of patients with diabetes. The mortality rate following amputation in a patient with diabetes is alarmingly high. Preventive treatment is pivotal to avoid the numerous complications associated with diabetic ulcerations. However, at the onset of ulceration, early treatment under the supervision and guidance of a specialist can result in remission. Diabetic peripheral neuropathy is also a life-altering and debilitating disease. Although some patients experience numbness, some experience pain that can be sharp, shooting, and tingling. Although treatment is challenging and often requires medication, newer modalities, such as stimulation and physical therapy, have shown promise in reversing the devastating effects of peripheral neuropathy.

Histopathological assessment of a two-stage reconstructive procedure of the infected Charcot foot

INTRODUCTION

Charcot neuropathic osteoarthropathy (CN) can be complicated by osteomyelitis (OM). Surgery is a standard procedure to treat OM including debridement and interposition of antibiotic-loaded cement (ABLC) spacer. The course of CN and OM was investigated on a histopathological level.

MATERIALS AND METHODS

Diabetic patients (n = 15) suffering from CN and midfoot OM underwent surgical debridement and interposition of ABLC was interposed. 6 weeks later, ABLC was removed and bone samples were taken again. Histopathological Charcot Score (HCS), Histopathological Osteomyelitis Evaluation Score (HOES) and microbiological assessment were used to evaluate osteomyelitic and neuroosteoarthropathic activity at both time points.

RESULTS

Interposition of ABLC leads to microbiological/histopathological eradication of OM in 73%/87% of patients. CN activity-measured by HCS-could be reduced from moderate to low activity by ABLC spacer and correlated with HOES.

CONCLUSIONS

CN activity could be reduced by surgery. It can be suggested that neuroosteoarthropathic activity measured by HCS is triggered by OM.

A Wound Environment Control System to Avoid Major Amputation in Diabetic Foot Ulcers

We report the case of a 58-year-old patient with a diabetic foot lesion at high risk of major amputation successfully treated by a new innovative wound environment control system.

An older diabetes-induced mice model for studying skin wound healing

Advances in wound treatment depend on the availability of animal models that reflect key aspects of human wound healing physiology. To this date, the accepted mouse models do not reflect defects in the healing process for chronic wounds that are associated with type two diabetic skin ulcers. The long term, systemic physiologic stress that occurs in middle aged or older Type 2 diabetes patients is difficult to simulate in preclinical animal model. We have strived to incorporate the essential elements of this stress in a manageable mouse model: long term metabolic stress from obesity to include the effects of middle age and thereafter onset of diabetes. At six-weeks age, male C57BL/6 mice were separated into groups fed a chow and High-Fat Diet for 0.5, 3, and 6 months. Treatment groups included long term, obesity stressed mice with induction of diabetes by streptozotocin at 5 months, and further physiologic evaluation at 8 months old. We show that this model results in a severe metabolic phenotype with insulin resistance and glucose intolerance associated with obesity and, more importantly, skin changes. The phenotype of this older age mouse model included a transcriptional signature of gene expression in skin that overlapped that observed with elderly patients who develop diabetic foot ulcers. We believe this unique old age phenotype contrasts with current mice models with induced diabetes.

Necrotizing fasciitis due to Streptococcus constellatus in a patient with uncontrolled diabetes and bilateral diabetic foot ulceration

INTRODUCTION

Streptococcus constellatus is commensal flora of the oropharyngeal, gastrointestinal, and genitourinary tracts with a proclivity for abscess formation. Bacteremia due to S constellatus is rare; however, rising incidences have been reported, particularly in patients with diabetes. Prompt surgical debridement and antibiotic therapy with a cephalosporin are the mainstays of treatment.

CASE REPORT

The case presented here involves a patient with poorly controlled diabetes who had necrotizing soft tissue infection secondary to S constellatus. The infection originated from bilateral diabetic foot ulcerations that led to bacteremia and sepsis.

CONCLUSION

Immediate source control with wide and aggressive surgical debridement, initial empiric broad-spectrum antibiotic therapy followed by tailored treatment based on deep operative cultures, and staged closure led to effective limb-salvage and life-sparing intervention for this patient.

Albuminuric diabetic kidney disease predicts foot ulcers in type 2 diabetes

Diabetic Foot Ulcers (DFU) are feared among individuals with diabetic kidney disease (DKD), but it is unclear whether they are more frequent, especially in normoalbuminuric DKD. Five hundred and twenty patients admitted in our diabetology ward from 2007 to 2017 were followed up during 54 ± 26 months. New DFUs were registered, and their relationship with the initial renal status was analyzed by LogRank and multivariate Cox regression analysis. The 520 subjects were mainly men (57.9 %), 62 ± 9 years old, with a duration of diabetes of 14 ± 10 years, HbA1c: 8.7 ± 1.8 % (72 ± 19 mmol/mol), and complications: 33.7 % macroangiopathies, 22.1 % previous foot ulcers, 44.8 % DKD, 26.9 % retinopathies. Fifty-seven new DFU occurred, mainly in subjects with DKD. DKD was related to later DFU (HR: 1.79; 95%CI: 1.05-3.07), this relationship stayed significant adjusted for age, gender, and a history of previous DFU (HR: 3.61; 95%CI: 2.11-6.18), and further adjusted for the duration of diabetes, HbA1c, BMI, arterial hypertension, and dyslipidemia. Among the 233 subjects with DKD, 129 (55.3 %) had an isolated AER > 30 mg/24H, 41 (17.6 %) had an isolated eGFR<60 mL/min/1.73 m², and 63 (27.0 %) cumulated both abnormalities. By Cox regression analysis adjusted for age and gender, albuminuric DKDs were related to later DFU: with eGFR≥60: HR: 1.91; 95%CI: 1.02-3.59, with eGFR<60: HR: 2.53; 95%CI: 1.25-5.10, whereas normoalbuminuric DKD was not: HR: 1.04; 95%CI: 0.35-3.07, despite similar rates of neuropathies, peripheral arterial diseases, and retinopathies. In people with type 2 diabetes, albuminuric DKD was associated with two to three folds increased risk of DFUs, whereas normoalbuminuric DKD was not.