Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach?

Effect of different casting design characteristics on offloading the diabetic foot

BACKGROUND

Non-removable knee-high devices, such as a total contact cast (TCC), are recommended for offloading diabetic plantar forefoot ulcers. However, it is insufficiently known how each of the different design characteristics of these devices contribute to offloading the diabetic foot.

RESEARCH QUESTION

What is the offloading effect of the different design characteristics that make up a non-removable knee-high cast for people with diabetes and active or previous plantar forefoot ulcers?

METHODS

Sixteen persons with diabetes, peripheral neuropathy and a healed or active plantar forefoot ulcer had their plantar pressures measured during walking in a non-removable knee-high device (TCC), in that device made removable (BTCC), in that device made below-ankle (cast shoe), in that cast shoe worn with a different walking sole and in a newly made cast shoe without a custom-moulded foot-device interface. Peak pressures, force-time integral, and perceived walking comfort were assessed.

RESULTS

Compared with the BTCC, peak pressures in the TCC were 47% (P = 0.028), 26% (P = 0.003) and 15% (P = 0.050) lower at the hallux, midfoot and (previous) ulcer location, respectively. Compared to the cast shoe, peak pressures in the BTCC were 39-43% and 47% (both P < 0.001) lower in the forefoot regions and (previous) ulcer location, respectively. The total force-time integral was 21% and 11% (P < 0.007) lower in the TCC and BTCC compared to the cast shoe. Perceived walking comfort was 5.6 in the TCC and 6.5 in the BTCC (P = 0.037). Effects of the other design characteristics (i.e. walking sole and plantar moulding) were non-significant.

SIGNIFICANCE

The TCC gives superior offloading, mostly because of being a knee-high and non-removable device, providing an optimal 'shaft effect'. The TCC does, however, negatively affect walking comfort. These results aid decision-making in offloading diabetic plantar forefoot ulcers.

Decreasing an Offloading Device's Size and Offsetting Its Imposed Limb-Length Discrepancy Lead to Improved Comfort and Gait

OBJECTIVE

Patient adherence is a challenge in offloading diabetic foot ulcers (DFUs) with removable cast walkers (RCWs). The size and weight of an RCW, changes to gait, and imposed limb-length discrepancies may all discourage adherence. This study sought to determine whether RCW size and provision of a contralateral limb lift affected users' comfort and gait.

RESEARCH DESIGN AND METHODS

Twenty-five individuals at risk for DFUs completed several 20-m walking trials under five footwear conditions: bilateral standardized shoes, a knee-high RCW with shoe with or without an external shoe lift contralaterally, and an ankle-high RCW with shoe with or without an external shoe lift contralaterally. Perceived comfort ratings were assessed through the use of visual analog scales. Spatial and temporal parameters of gait were captured by an instrumented walkway, and plantar pressure was measured and recorded using pedobarographic insoles.

RESULTS

The bilateral shoes condition was reported to be most comfortable; both RCW conditions without the lift were significantly less comfortable (P < 0.01). In contrast to the ankle-high RCW, the knee-high RCW resulted in significantly slower walking (5.6%; P < 0.01) but greater offloading in multiple forefoot regions of the offloaded foot (6.8-8.1%; P < 0.01). Use of the contralateral shoe lift resulted in significantly less variability in walking velocity (52.8%; P < 0.01) and reduced stance time for the offloaded foot (2.6%; P = 0.01), but it also reduced offloading in multiple forefoot regions of the offloaded foot (3.7-6.0%; P < 0.01).

CONCLUSIONS

Improved comfort and gait were associated with the ankle-high RCW and contralateral limb lift. Providing this combination to patients with active DFUs may increase offloading adherence and subsequently improve healing.

A Narrative Review of the Benefits and Risks of Total Contact Casts in the Management of Diabetic Foot Ulcers

Total contact casts are recognized as the gold standard treatment for neuropathic plantar diabetic foot ulceration, endorsed by all national and international consensus papers. Despite this, research has shown that there is a dichotomy between the existing evidence which supports the use of total contact casts in the management of diabetic foot ulcers and its use in clinical practice. This article aims to highlight the benefits, risks, and barriers associated with total contact cast use in the management of diabetic foot ulcers in the clinical setting, with an emphasis on existing research carried out in this field to encourage change in clinical practice and utilization of this effective treatment modality.

Diabetic foot management: multidisciplinary approach for advanced lesion rescue

The diabetic foot is a complication of diabetes affecting 15% of diabetics in their lives. It is associated to diabetic neuropathy and peripheral vascular disease and its incidence has increased. The ulceration is the initial cause of a dramatic process leading, if not correctly treated, to amputations. Both neuropathy, neuro-ischemia and infections have a role in determining healing or worsening of the lesions and 85% of all amputations in diabetic patients are preceded by a foot ulceration deteriorating to a severe gangrene or infection. The different causative agents and the different clinical presentations of diabetic foot ask a multidisciplinary approach in order to address treatments to the final goals, the prevention of the amputations and the maintenance of a functional foot able with weight-bearing ability. Many professional figures, diabetologists, surgeons (both general and vascular and orthopedics), interventional radiologists, infectious diseases specialists, specialized nurses, podiatrists, orthotic technicians, are called to apply their knowledges to the diabetic patients affected by diabetic foot in a virtuous circle leading to reach the goals, with the imperative action of the multidisciplinary team. The so organized center will allow both a correct and rapid diagnosis, the use in ambulatorial environments of modern tools, or the hospitalization in multitasking wards, in which all the complications and the necessary treatments are possible, both in emergencies or in elective way, considering both revascularizations and surgery.

Recent Advances and Future Opportunities to Address Challenges in Offloading Diabetic Feet: A Mini-Review

Diabetic foot ulcers (DFU) are a substantial dilemma for geriatric individuals with diabetes. The breakdown in tissue associated with DFU is typically a result of repetitive cycles of physical stress placed on the feet during weight-bearing activity. Accordingly, a key tenet in healing as well as preventing DFU is the use of offloading footwear to redistribute physical stress away from high stress locations such as bony prominences. Over the last several years there has been a substantial amount of effort directed at better understanding and implementing the practice of offloading. A review of this work as well as relevant technological advances is presented in this paper. Specifically, we will discuss the following topics in association with offloading diabetic feet: achieving optimal offloading, dosing activity/physical stress, thermal monitoring to detect preulcerative tissue damage, adherence with offloading devices, and optimizing the user experience. In addition to presenting progress to date, potential directions for further advancement are discussed.

Lower-extremity dynamics of walking in neuropathic diabetic patients who wear a forefoot-offloading shoe

BACKGROUND

A forefoot-offloading shoes has a negative-heel rocker outsole and is used to treat diabetic plantar forefoot ulcers, but its mechanisms of action and their association with offloading and gait stability are not sufficiently clear.

METHODS

Ten neuropathic diabetic patients were tested in a forefoot-offloading shoe and subsequently in a control shoe with no specific offloading construction, both worn on the right foot (control shoe on left), while walking at 1.2m/s. 3D-instrumented gait analysis and simultaneous in-shoe plantar pressure measurements were used to explain the shoe's offloading efficacy and to define centre-of-pressure profiles and left-to-right symmetry in ankle joint dynamics (0-1, 1:maximum symmetry), as indicators for gait stability.

FINDINGS

Compared to the control shoe, peak forefoot pressures, vertical ground reaction force, plantar flexion angle, and ankle joint moment, all in terminal stance, and the proximal-to-distal centre-of-pressure trajectory were significantly reduced in the forefoot-offloading shoe (P<0.01). Peak ankle joint power was 51% lower in the forefoot-offloading shoe compared to the control shoe: 1.61 (0.35) versus 3.30 (0.84) W/kg (mean (SD), P<0.001), and was significantly associated with forefoot peak pressure (R²=0.72, P<0.001). Left-to-right symmetry in the forefoot-offloading shoe was 0.39 for peak ankle joint power.

INTERPRETATION

By virtue to their negative-heel rocker-outsole design, forefoot-offloading shoes significantly alter a neuropathic diabetic patient's gait towards a reduced push-off power that explains the shoe's offloading efficacy. However, gait symmetry and stability are compromised, and may be factors in the low perceived walking discomfort and limited use of these shoes in clinical practice. Shoe modifications (e.g. less negative heel, a more cushioning insole) may resolve this trade-off between efficacy and usability.

The efficacy of removable devices to offload and heal neuropathic plantar forefoot ulcers in people with diabetes: a single-blinded multicentre randomised controlled trial

Non-removable offloading is the 'gold standard' treatment for neuropathic diabetic plantar forefoot ulcers. However, removable offloading is the common 'standard of care'. We compared three removable offloading devices for ulcer healing efficacy. In this multicentre, randomised controlled trial, 60 persons with neuropathic diabetic plantar forefoot ulcers were randomly assigned to wear a custom-made knee-high cast [BTCC (bivalved TCC)], custom-made ankle-high cast shoe or a prefabricated ankle-high forefoot-offloading shoe (FOS). Primary outcome was healing at 12 weeks. Dynamic plantar pressures, daily stride count and treatment adherence were assessed on a randomly selected subset (n = 35). According to intention-to-treat analysis, 58% of patients healed with BTCC [OR 0·77 (95% CI 0·41-1·45) versus FOS], 60% with cast shoe [OR 0·81 (95% CI 0·44-1·49) versus FOS] and 70% with FOS (P = 0·70). Mean ± SD peak pressure in kPa at the ulcer site was 81 ± 55 for BTCC, 176 ± 80 for cast shoe and 107 ± 52 for FOS (P = 0·005); stride count was 4150 ± 1626, 3514 ± 1380 and 4447 ± 3190, respectively (P = 0·71); percentage of 2-week intervals that patients wore the device <50% of time was 17·3%, 5·2% and 4·9%, respectively. Non-significant differences in healing efficacy between the three devices suggest that, when non-removable offloading is contraindicated or not available, each can be used for plantar forefoot ulcer offloading. Efficacy is lower than previously found for non-removable offloading maybe because suboptimal adherence and high stride count expose the patient to high repetitive stresses. These factors should be carefully considered in decision making regarding ulcer treatment.

Outcomes Achieved With Use of a Prefabricated Roll-On Total Contact Cast

BACKGROUND

The total contact cast (TCC) is considered the gold standard for offloading of plantar diabetic foot ulcerations, yet its use remains suboptimal for a variety of reasons. Prefabricated TCC systems have been developed to help enhance TCC use. The primary objective of this study was to determine if healing rates obtained with use of a prefabricated roll-on TCC were similar to those reported with conventional TCC use. Secondary outcomes measured were the incidence of iatrogenic ulceration, amputation, and recurrent ulceration, and patient tolerance of the device.

METHODS

A retrospective chart review was performed on all patients in whom TCC was used for treatment of an ulceration at our institution from April 2013 to December 2016. Seventy patients (132 ulcerations) were identified.

RESULTS

An 85.6% healing rate was achieved. Five subjects (7.1%) sustained 11 iatrogenic ulcerations. All resolved with local treatment and continued casting. Thirteen subjects (18.6%) underwent amputation. No amputation occurred because of TCC application technique or use. Fifteen ulcerations (12 subjects, 17.1%) recurred. Greater than 70% resolved with re-initiation of TCC use. Forty-three subjects (61.4%) tolerated use of the prefabricated roll-on TCC.

CONCLUSION

Similar healing rates and reduced rates of iatrogenic ulceration, amputation, and recurrent ulceration were attained with use of a prefabricated roll-on TCC. These results, good patient tolerance, and the reduced administrative and clinical time related to supply acquisition, training, and proper application supports use of this device as a viable alternative to a conventional TCC for treatment of plantar neuropathic foot ulcerations.

LEVEL OF EVIDENCE

Level IV, case series.

Novel In-Shoe Exoskeleton for Offloading of Forefoot Pressure for Individuals With Diabetic Foot Pathology

INTRODUCTION

Infected diabetic foot ulcers are the leading cause of lower limb amputation. This study evaluated the ability of in-shoe exoskeletons to redirect forces outside of body and through an exoskeleton as an effective means of offloading plantar pressure, the major contributing factor of ulceration.

METHODS

We compared pressure in the forefoot and hind-foot of participants (n = 5) shod with novel exoskeleton footwear. Plantar pressure readings were taken during a 6-m walk at participant's self-selected speed, and five strides were averaged. Results were taken with Achilles exotendon springs disengaged as a baseline, followed by measurements taken with the springs engaged.

RESULTS

When springs were engaged, all participants demonstrated a decrease in forefoot pressure, averaging a 22% reduction ( P < .050). Patient feedback was universally positive, preferring the exotendon springs to be engaged and active.

CONCLUSIONS

Offloading is standard of care for reducing harmful plantar pressure, which may lead to foot ulcers. However, current offloading modalities are limited and have issues. This proof-of-concept study proposed a novel offloading approach based on an exoskeleton solution. Results suggest that when the novel exoskeletons were deployed in footwear and exotendon springs engaged, force was successfully transferred from the lower leg through the exoskeleton-enabled shoe to ground, reducing load on the forefoot. The results need to be confirmed in a larger sample. Another study is warranted to examine the effectiveness of this offloading to prevent diabetic foot ulcer, while minimizing gait alteration in daily physical activities.

Plantar pressures are elevated in people with longstanding diabetes-related foot ulcers during follow-up

Objective

High plantar pressures are implicated in the development of diabetes-related foot ulcers. Whether plantar pressures remain high in patients with chronic diabetes-related foot ulcers over time is uncertain. The primary aim of this study was to compare plantar pressures at baseline and three and six months later in participants with chronic diabetes-related foot ulcers (cases) to participants without foot ulcers (controls).

Methods

Standardised protocols were used to measure mean peak plantar pressure and pressure-time integral at 10 plantar foot sites (the hallux, toes, metatarsals 1 to 5, mid-foot, medial heel and lateral heel) during barefoot walking. Measurements were performed at three study visits: baseline, three and six months. Linear mixed effects random-intercept models were utilised to assess whether plantar pressures differed between cases and controls after adjusting for age, sex, body mass index, neuropathy status and follow-up time. Standardised mean differences (Cohen’s d) were used to measure effect size.

Results

Twenty-one cases and 69 controls started the study and 16 cases and 63 controls completed the study. Cases had a higher mean peak plantar pressure at several foot sites including the toes (p = 0.005, Cohen’s d = 0.36) and mid-foot (p = 0.01, d = 0.36) and a higher pressure-time integral at the hallux (p<0.001, d = 0.42), metatarsal 1 (p = 0.02, d = 0.33) and mid-foot (p = 0.04, d = 0.64) compared to controls throughout follow-up. A reduction in pressure-time integral at multiple plantar sites over time was detected in all participants (p<0.05, respectively).

Conclusions

Plantar pressures assessed during gait are higher in diabetes patients with chronic foot ulcers than controls at several plantar sites throughout prolonged follow-up. Long term offloading is needed in diabetes patients with diabetes-related foot ulcers to facilitate ulcer healing.

An innovative sealed shoe to off-load and heal diabetic forefoot ulcers - a feasibility study

Background: Non-removable knee-high devices are the gold standard to treat diabetic foot ulcers located on the plantar forefoot, but they immobilize the ankle, which restricts daily life activities and has negative effects on joint functioning.

Objective: To investigate the feasibility of sealing a therapeutic shoe to off-load and heal diabetic forefoot ulcers.

Design: A case series of seven men with type 2 diabetes and a metatarsal head ulcer were prescribed therapeutic shoes and custom-made insoles. The shoe was sealed with a plastic band. Off-loading was assessed with the F-scan pressure measurement system. Adherence to wearing the shoe was assessed with a temperature sensor and by documenting the status of the seal.

Results: The off-loading was effective and all ulcers healed. Median time to healing was 56 days (range 8–160). Complications were secondary ulcer (n = 1) and plantar hematoma (n = 1). Five of seven participants did not disturb the seal.

Conclusions: Sealing a therapeutic shoe is a feasible way to off-load and heal forefoot ulcers. A controlled trial is needed to compare the effectiveness and safety of a sealed shoe to other non-removable devices.

The Role of Pressure Offloading on Diabetic Foot Ulcer Healing and Prevention of Recurrence

BACKGROUND

An increased plantar pressure is a causative factor in the development of plantar foot ulcers in people with diabetes mellitus, and ulcers are a precursor of lower extremity amputation.

METHODS

In this article, the evidence is reviewed that relieving areas of increased plantar pressure (ie, offloading) can heal plantar foot ulcers and prevent their recurrence.

RESULTS

Noninfected, nonischemic neuropathic plantar forefoot ulcers should heal in 6 to 8 weeks with adequate offloading. Recent meta-analyses and systematic reviews show that nonremovable knee-high devices are most effective. This is probably because they eliminate the problem of nonadherence with the use of a removable device. Studies show a large discrepancy between evidence-based recommendations on offloading and what is used in clinical practice. Many clinics continue to use methods that are less effective or have not been proven to be effective, while ignoring evidence-based methods. Strategies are proposed to address this issue, notably the adoption and implementation of recent international guidelines by professional societies and a stronger focus of clinicians on expedited healing. For the prevention of plantar foot ulcer recurrence in high-risk patients, 2 recent trials have shown that the incidence of recurrence can be significantly reduced with custom-made footwear that has a demonstrated pressure-relieving effect through guidance by plantar pressure measurements, under the condition that the footwear is worn.

CONCLUSION

This review helps to inform clinicians about effective offloading treatment for healing plantar foot ulcers and preventing their recurrence.

Evaluating Iatrogenic Complications of the Total-Contact Cast: An 8-Year Retrospective Review at Cleveland Clinic

BACKGROUND

Total-contact casting is an effective method to treat various pathologic abnormalities in patients with diabetic neuropathy, but its use is frequently associated with iatrogenic complications.

METHODS

The largest retrospective review to date of iatrogenic complications of total-contact casts was conducted over an 8-year period at Cleveland Clinic.

RESULTS

In the past 8 years, 23% of patients developed complications, and the most common complication was a new heel ulcer formation. Of these complications, 92.1% resolved, 6.4% were lost to follow-up, and 1.4% resulted in a partial foot amputation. Mean cast duration was 10.3 days for patients who developed a total-contact cast iatrogenic complication. The most common indication for the use of a total-contact cast was a neuropathic foot ulceration.

CONCLUSIONS

The results of this study support the use of total-contact casting in the insensate patient with diabetes. However, adequate staff training in total-contact cast application is recommended to reduce complications.

Physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers: a critical review

Obesity and a sedentary lifestyle are common challenges among individuals at risk of diabetic foot ulcers. While substantial research exists on physical activity interventions in adults with diabetes, those at greatest risk for foot ulceration were often excluded or not well represented. Both at-risk patients and their clinicians may be hesitant to increase physical activity because of their perception of diabetic foot ulcer risks. Physical activity is not contraindicated for those at risk of diabetic foot ulcer, yet patients at risk present with unique barriers to initiating increases in physical activity. This review focuses upon the physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers. Offloading, diabetic peripheral neuropathy, depression, pain, self-efficacy and social support, diabetic foot ulcer risk-specific beliefs and emotions, and research to date on exercise interventions in this population are all discussed. Additionally, recommendations for implementing and researching physical activity interventions for individuals at risk for diabetic foot ulcer are provided. Copyright © 2016 John Wiley & Sons, Ltd.

The effectiveness of felt padding for offloading diabetes-related foot ulcers, at baseline and after one week of wear

AIM

Felt padding is used to offload diabetes-related foot ulceration although limited quality data exists to support its use. This study aimed to quantify pressure offloading from neuropathic plantar foot ulcers in a clinical setting, when felt padding is first applied and after wear.

METHODS

This study used a within-subjects, repeated measures design. Data was collected in a high-risk foot service. Peak plantar pressures, contact area and contact time were measured in 15 diabetes subjects with 16 non-complicated plantar neuropathic foot ulcers, with: no felt padding, newly applied felt padding and felt padding after one week of wear.

RESULTS

Statistically significant decreases in peak pressure of 49% and 32% were measured with newly applied felt padding (188.0kPa; p<0.001) and worn felt padding (248kPa; p=0.003) respectively, compared to no padding (367.2kPa). Worn felt offloaded 32% less pressure than new felt however this did not reach statistical significance (p=.069). Corresponding increases in contact area of 18% and 14% occurred with newly applied felt padding (156.9cm²; p<.001) and worn felt padding (150.6cm²; p=0.003) compared to no padding (132.5cm²). Contact time was constant across testing conditions.

CONCLUSIONS

New felt padding offloaded on average half the pressure applied to sites of plantar neuropathic ulceration, which reduced to one third after wear. Increased contact area under the foot is a possible mechanism contributing to pressure reduction. Further studies are required to evaluate effectiveness of felt padding directly on ulcer healing.

Neuropathic Minimally Invasive Surgeries (NEMESIS):: Percutaneous Diabetic Foot Surgery and Reconstruction

Patients with peripheral neuropathy associated with ulceration are the nemesis of the orthopedic foot and ankle surgeon. Diabetic foot syndrome is the leading cause of peripheral neuropathy, and its prevalence continues to increase at an alarming rate. Poor wound healing, nonunion, infection, and risk of amputation contribute to the understandable caution toward this patient group. Significant metalwork is required to hold these technically challenging deformities. Neuropathic Minimally Invasive Surgeries is an addition to the toolbox of management of the diabetic foot. It may potentially reduce the risk associated with large wounds and bony correction in this patient group.

The evaluation of off-loading using a new removable oRTHOsis in DIABetic foot (ORTHODIAB) randomized controlled trial: study design and rational

BACKGROUND

Off-loading is essential for diabetic foot management, but remains understudied. The evaluation of Off-loading using a new removable oRTHOsis in DIABetic foot (ORTHODIAB) trial aims to evaluate the efficacy of a new removable device "Orthèse Diabète" in the healing of diabetic foot.

METHODS/DESIGN

ORTHODIAB is a French multi-centre randomized, open label trial, with a blinded end points evaluation by an adjudication committee according to the Prospective Randomized Open Blinded End-point. Main endpoints are adjudicated based on the analysis of diabetic foot photographs. Orthèse Diabète is a new removable off-loading orthosis (PROTEOR, France) allowing innovative functions including real-time evaluation of off-loading and estimation of patients' adherence. Diabetic patients with neuropathic plantar ulcer or amputation wounds (toes or transmetatarsal) are assigned to one of 2 parallel-groups: Orthèse Diabète or control group (any removable device) according to a central computer-based randomization. Study visits are scheduled for 6 months (days D7 and D14, and months M1, M2, M3, and M6). The primary endpoint is the proportion of patients whose principal ulcer is healed at M3. Secondary endpoints are: the proportion of patients whose principal ulcer is healed at M1, M2 and M6; the proportion of patients whose initial ulcers are all healed at M1, M2, M3, and M6; principal ulcer area reduction; time-related ulcer-free survival; development of new ulcers; new lower-extremity amputation; infectious complications; off-loading adherence; and patient satisfaction. The study protocol was approved by the French National Agency for Medicines and Health Products Safety, and by the ethics committee of Saint-Louis Hospital (Paris). Comprehensive study information including a Patient Information Sheet has been provided to each patient who must give written informed consent before enrolment. Monitoring, data management, and statistical analyses are providing by UMANIS Life Science (Paris), independently to the sponsor. Since 27/10/2013, 13 centres have agreed to participate in this study, 117 participants were included, and 70 have achieved the study schedules. The study completion is expected for the end of 2016, and the main results will be published in 2017.

CONCLUSION

ORTHODIAB trial evaluates an innovating removable off-loading device, seeking to improve diabetic foot healing (ClinicalTrials.gov identifier: NCT01956162).

Role and Determinants of Adherence to Off-loading in Diabetic Foot Ulcer Healing: A Prospective Investigation

OBJECTIVE

Studies indicate that off-loading adherence is low in patients with diabetic foot ulcers (DFUs), which may subsequently delay healing. However, there is little empirical evidence for this relationship or the factors that influence adherence.

RESEARCH DESIGN AND METHODS

This prospective, multicenter, international study of 79 (46 from the U.K. and 33 the U.S.) persons with type 2 diabetes and plantar DFUs assessed the association between off-loading adherence and DFU healing over a 6-week period. Additionally, potential demographic, disease, and psychological determinants of adherence were examined. DFUs were off-loaded with a removable device (77% a removable cast walker). Off-loading adherence was assessed objectively by activity monitors. Patient-reported measures included Hospital Anxiety and Depression Scale (HADS), Neuropathy and Foot Ulcer Quality of Life (NeuroQoL) instrument, and Revised Illness Perception Questionnaire (IPQ-R).

RESULTS

Off-loading adherence was monitored for 35 ± 10 days, and devices were used during 59 ± 22% of subjects' activity. In multivariate analyses, smaller baseline DFU size, U.K. study site, and better off-loading adherence predicted smaller DFU size at 6 weeks (P < 0.05). Better off-loading adherence was, in turn, predicted by larger and more severe baseline DFUs, more severe neuropathy, and NeuroQoL foot pain (P < 0.05). In contrast, greater NeuroQoL postural instability predicted worse off-loading adherence (P < 0.001). HADS and IPQ-R measures were not significantly associated with off-loading adherence.

CONCLUSIONS

Off-loading adherence is associated with the amount of DFU healing that occurs, while postural instability is a powerful predictor of nonadherence. Clinicians should take this neuropathic symptom into consideration when selecting an off-loading device, as off-loading-induced postural instability may further contribute to nonadherence.

Improving rural and remote practitioners' knowledge of the diabetic foot: findings from an educational intervention

BACKGROUND

This study aimed to determine knowledge of national guidelines for diabetic foot assessment and risk stratification by rural and remote healthcare professionals in Western Australia and their implementation in practice. Assessment of diabetic foot knowledge, availability of equipment and delivery of foot care education in a primary healthcare setting at baseline enabled evaluation of the effectiveness of a diabetic foot education and training program for generalist healthcare professionals.

METHODS

This study employed a quasi-experimental pre-test/post-test study design. Healthcare practitioners' knowledge, attitudes and practice of diabetic foot assessment, diabetic foot risks, risk stratification, and use of the 2011 National Health and Medical Research Council Guidelines were investigated with an electronic pre-test survey(.) Healthcare professionals then undertook a 3-h education and training workshop before completing the electronic post-test knowledge, attitudes and practice survey. Comparison of pre-test/post-test survey findings was used to assess the change in knowledge, attitudes and intended practice due to the workshops.

RESULTS

Two hundred and forty-six healthcare professionals from two rural and remote health regions of Western Australia participated in training workshops. Monofilaments and diabetes foot care education brochures, particularly brochures for Aboriginal people, were reported as not readily available in rural and remote health services. For most participants (58 %), their post-test knowledge score increased significantly from the pre-test score. Use of the Guidelines in clinical settings was low (19 %). The healthcare professionals' baseline diabetic foot knowledge was adequate to correctly identify the high risk category. However, stratification of the intermediate risk category was poor, even after training.

CONCLUSION

This study reports the first assessment of Western Australia's rural and remote health professionals' knowledge, attitudes and practices regarding the diabetic foot. It shows that without training, generalists' levels of knowledge concerning the diabetic foot was low and they were unlikely to assess foot risk. The findings from this study in a rural and remote setting cast doubt on the ability of generalist healthcare professionals to stratify risk appropriately, especially for those at intermediate risk, without clinical decision support tools.

Static and Dynamic Predictors of Foot Progression Angle in Individuals with and without Diabetes Mellitus and Peripheral Neuropathy

INTRODUCTION

Foot progression angle (FPA) is a predictor of elevated regional plantar stresses and loads, which are indicators of dermal injury risk in individuals with diabetes mellitus and peripheral neuropathy (DMPN). FPA accounts for 15-45% of the variance in plantar stresses and loads in adults with DMPN. However, the biomechanical factors underlying an "out-toeing" gait pattern in this clinical population have not been examined. The primary purpose of this study was to identify static and dynamic predictors of foot progression angle magnitude in adults with and without DMPN.

METHODS

Thirty-three adults with and 12 adults without diabetes mellitus participated. Hip rotation, ankle dorsiflexion, and resting calcaneal stance position were measured using a standard goniometer. Kinematic and kinetic data were collected during walking.

RESULTS AND DISCUSSION

Static predictor variables did not significantly predict foot progression angle magnitude using multiple regression analysis. Of the dynamic predictor variables, thigh and shank lateral rotation accounted for 37% of foot progression angle variance (p<.01).

CONCLUSIONS

Our results show that dynamic measures of external rotation of proximal segments (thigh, shank) during gait are strong predictors of foot progression angle. Static measures of limited joint mobility and joint position do not predict foot progression angle. These findings suggest that targeting the thigh and shank rotation using verbal or tactile cueing may be a potential strategy when trying to alter walking movement patterns towards decreasing external (lateral) FPA to minimize risk of elevated regional plantar stresses in adults with DMPN at risk for ulceration.

The Applicability of Plantar Padding in Reducing Peak Plantar Pressure in the Forefeet of Healthy AdultsImplications for the Foot at Risk

BACKGROUND

We investigated the effectiveness and durability of two types of plantar padding, the plantar metatarsal pad and the single wing plantar cover, which are commonly used for reducing forefoot plantar pressures.

METHODS

Mean peak plantar pressure and impulse at the hallux and at the first, second, third, and fourth metatarsophalangeal joints across both feet were recorded using the two-step method in 18 individuals with normal asymptomatic feet. Plantar paddings were retained for 5 days, and their durability and effectiveness were assessed by repeating the foot plantar measurement at baseline and after 3 and 5 days.

RESULTS

The single wing plantar cover devised from 5-mm felt adhesive padding was effective and durable in reducing peak plantar pressure and impulse at the first metatarsophalangeal joint (P = .001 and P = .015, respectively); however, it was not found to be effective in reducing peak plantar pressure and impulse at the hallux (P = .782 and P = .845, respectively). The plantar metatarsal pad was not effective in reducing plantar forefoot pressure and impulse at the second, third, and fourth metatarsophalangeal joints (P = .310 and P = .174, respectively).

CONCLUSIONS

These results imply limited applicability of the single wing plantar cover and the plantar metatarsal pad in reducing hallux pressure and second through fourth metatarsophalangeal joint pressure, respectively. However, the single wing plantar cover remained durable for the 5 days of the trial and was effective in reducing the peak plantar pressure and impulse underneath the first metatarsophalangeal joint.

Diabetic Peripheral Neuropathy: The Learning Curve

Living with diabetes mellitus and its complications can be challenging, but treatment by a specialized wound care staff adept in treating diabetic foot ulcers and educating patients about care can ensure favorable outcomes.

Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot

Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.

Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review

BACKGROUND

Footwear and offloading techniques are commonly used in clinical practice for preventing and healing of foot ulcers in persons with diabetes. The goal of this systematic review is to assess the medical scientific literature on this topic to better inform clinical practice about effective treatment.

METHODS

We searched the medical scientific literature indexed in PubMed, EMBASE, CINAHL, and the Cochrane database for original research studies published since 1 May 2006 related to four groups of interventions: (1) casting; (2) footwear; (3) surgical offloading; and (4) other offloading interventions. Primary outcomes were ulcer prevention, ulcer healing, and pressure reduction. We reviewed both controlled and non-controlled studies. Controlled studies were assessed for methodological quality, and extracted key data was presented in evidence and risk of bias tables. Uncontrolled studies were assessed and summarized on a narrative basis. Outcomes are presented and discussed in conjunction with data from our previous systematic review covering the literature from before 1 May 2006.

RESULTS

We included two systematic reviews and meta-analyses, 32 randomized controlled trials, 15 other controlled studies, and another 127 non-controlled studies. Several randomized controlled trials with low risk of bias show the efficacy of therapeutic footwear that demonstrates to relief plantar pressure and is worn by the patient, in the prevention of plantar foot ulcer recurrence. Two meta-analyses show non-removable offloading to be more effective than removable offloading for healing plantar neuropathic forefoot ulcers. Due to the limited number of controlled studies, clear evidence on the efficacy of surgical offloading and felted foam is not yet available. Interestingly, surgical offloading seems more effective in preventing than in healing ulcers. A number of controlled and uncontrolled studies show that plantar pressure can be reduced by several conservative and surgical approaches.

CONCLUSIONS

Sufficient evidence of good quality supports the use of non-removable offloading to heal plantar neuropathic forefoot ulcers and therapeutic footwear with demonstrated pressure relief that is worn by the patient to prevent plantar foot ulcer recurrence. The evidence base to support the use of other offloading interventions is still limited and of variable quality. The evidence for the use of interventions to prevent a first foot ulcer or heal ischemic, infected, non-plantar, or proximal foot ulcers is practically non-existent. High-quality controlled studies are needed in these areas.

Impact of foot progression angle modification on plantar loading in individuals with diabetes mellitus and peripheral neuropathy

AIMS

To determine if participants can reduce foot progression angle (FPA), and if FPA reduction decreases regional plantar stresses and forces in individuals with diabetes.

METHODS

Design: Three-group cross-sectional design with repeated measures. subjects: twenty-eight participants either with diabetes mellitus (DM), diabetes and peripheral neuropathy with (DMPN+NPU) or without a prior history of ulceration (DMPN-NPU) were studied. Intervention: Participants were first instructed to walk over a 3.6 m walkway at their preferred FPA, and then to walk with their foot aligned parallel with the line of gait progression at their self-selected speed. Dynamic plantar kinetics in six masked regions were collected using an EMED-st-P-2 pedobarograph. Main measures: Primary outcome measures were FPA, peak plantar pressure (PPP), and force-time integral (FTI). A repeated measures ANOVA was conducted to determine group differences in FPA for both walking conditions. Regional differences in PPPs and FTIs between preferred and corrected walking conditions were analyzed using repeated measures ANCOVA.

RESULTS

Participants showed a reduction in FPA magnitude on the 'Involved' foot between the preferred and corrected walking conditions (p<0.01). There were no differences in PPPs or FTIs in any mask between walking conditions (p>0.05).

CONCLUSION

Results from this investigation offer important evidence that people with diabetes can modify their FPA with a simple intervention of visual and verbal cueing. Future research should examine if gait retraining strategies in regular footwear more effectively offload areas of elevated regional plantar stresses and forces in adults with diabetes mellitus and peripheral neuropathy.

Treatment of chronic plantar ulcer of the diabetic foot using an irremovable windowed fibreglass cast boot: prospective study of 177 patients

The objective of this study was to evaluate the level of healing of chronic neuropathic plantar ulcers, using an irremovable windowed fibreglass cast boot, which is only opened after healing. A single-centre prospective study of a cohort of 177 diabetic patients with chronic neuropathic plantar ulcers was carried out. The duration of neuropathic plantar ulcers was 604 ± 808 days, with a mean surface area of 4.6 ± 6.5 cm(2) , a mean depth of 1.04 ± 1.08 cm and a mean volume of 5.9 ± 17.7 cm(3) . After a mean of 96 days of wearing a windowed fibreglass cast boot (min 9 days, max 664 days and median 68 days), the level of healing reached 83.6%, although 29 patients did not heal (16.4%). The compliance was at 95%. NPUs with bigger volumes (p = 0.037) and those located at the heels ( p = 0.004) had significantly lower healing levels. Twenty-one patients had moderate peripheral arterial disease (12%), and 24 patients were ostectomized for underlying osteomyelitis (14%), before inclusion. Moderate peripheral arterial disease (p = 0.970) or operated osteomyelitis (p = 0.128) did not modify the level of healing significantly, which were of 81% and 70.8%, respectively. Complications include 12 ulcers due to the windowed fibreglass cast boot (i.e. 7%) and two other ulcers being moderately infected, resulting in 2% of toe amputation, but there was no major amputation or phlebitis. The treatment of old and deep NPUs of the diabetic foot by wearing a windowed fibreglass cast boot without opening the boot prior to healing offers very high ulcer recovery levels. Windowed fibreglass cast boots were changed in only 26 cases (14.6%). In addition, compliance was excellent and of the order of 95%. Furthermore, moderate peripheral arterial disease or a recent ostectomy did not affect the efficacy of windowed fibreglass cast boot.

Grafix®, a Cryopreserved Placental Membrane, for the Treatment of Chronic/Stalled Wounds

Objective: To discuss the use of Grafix®, a commercially available, cryopreserved placental membrane, for the treatment of chronic/stalled wounds of different etiologies. Approach: To describe the unique composition of Grafix, to provide an overview of the existing clinical evidence supporting the benefits of Grafix for wound treatment, and to share the experience of the South Shore Hospital Center for Wound Healing (Weymouth, MA) with Grafix for the treatment of nonhealing wounds. Results: Clinical evidence supports the safety and efficacy of Grafix for the treatment of chronic/stalled wounds, including those that have failed other advanced treatment modalities. Innovation: Grafix is a cryopreserved placental membrane manufactured utilizing a novel technology that enables the preservation of all placental membrane components in their native state. Placental membranes have a unique composition of extracellular matrix, growth factors, and cells (including mesenchymal stem cells), which makes this tissue unique among other advanced biological wound treatment modalities. Conclusion: Clinical evidences support the benefits of Grafix for head-to-toe wound treatment.

Reduction of diabetic foot ulcer healing times through use of advanced treatment modalities

Diabetic wounds are a major health care problem associated with delayed healing and high amputation rates. This review systematically evaluated newer wound care therapies for the treatment of diabetic wounds. More recent means of approaching diabetic foot ulcers include various dressings, off-loading shoes, and bioengineered skin constructs and growth factors. Electrical stimulation, phototherapy, electromagnetic fields, and shockwave therapy have been further proposed as potential treatments. A brief overview of these treatments is presented using peer-reviewed evidenced-based literature. A review of the literature demonstrated that treatment of diabetic wounds has focused on either prevention of the wounds in the form of off-loading shoes or adequate protective dressings or on direct treatment of wounds with bioengineered skin constructs, growth factors, or medical devices that accelerate wound healing. The authors' conclusion, following extensive literature review, is that although excellent national and international guidelines exist regarding suggested approaches to the treatment of the diabetic foot ulcer, there is no definitive or universal consensus on the choice of specific treatment modalities. The importance of optimizing comorbidities and the disease state, hemodynamics, local and peripheral skin and wound care, and metabolic challenges while reducing biological and bacterial burden and minimizing trauma remain the primary approach, followed by choice of the most appropriate treatment material or product.

How do Australian podiatrists manage patients with diabetes? The Australian diabetic foot management survey

Background

Diabetic foot complications are the leading cause of lower extremity amputation and diabetes-related hospitalisation in Australia. Studies demonstrate significant reductions in amputations and hospitalisation when health professionals implement best practice management. Whilst other nations have surveyed health professionals on specific diabetic foot management, to the best of the authors’ knowledge this appears not to have occurred in Australia. The primary aim of this study was to examine Australian podiatrists’ diabetic foot management compared with best practice recommendations by the Australian National Health Medical Research Council.

Methods

A 36-item Australian Diabetic Foot Management survey, employing seven-point Likert scales (0 = Never; 7 = Always) to measure multiple aspects of best practice diabetic foot management was developed. The survey was briefly tested for face and content validity. The survey was electronically distributed to Australian podiatrists via professional associations. Demographics including sex, years treating patients with diabetes, employment-sector and patient numbers were also collected. Chi-squared and Mann Whitney U tests were used to test differences between sub-groups.

Results

Three hundred and eleven podiatrists responded; 222 (71%) were female, 158 (51%) from the public sector and 11–15 years median experience. Participants reported treating a median of 21–30 diabetes patients each week, including 1–5 with foot ulcers. Overall, participants registered median scores of at least “very often” (>6) in their use of most items covering best practice diabetic foot management. Notable exceptions were: “never” (1 (1 – 3)) using total contact casting, “sometimes” (4 (2 – 5)) performing an ankle brachial index, “sometimes” (4 (1 – 6)) using University of Texas Wound Classification System, and “sometimes” (4 (3 – 6) referring to specialist multi-disciplinary foot teams. Public sector podiatrists reported higher use or access on all those items compared to private sector podiatrists (p < 0.01).

Conclusions

This study provides the first baseline information on Australian podiatrists’ adherence to best practice diabetic foot guidelines. It appears podiatrists manage large caseloads of people with diabetes and are generally implementing best practice guidelines recommendations with some notable exceptions. Further studies are required to identify barriers to implementing these recommendations to ensure all Australians with diabetes have access to best practice care to prevent amputations.

Literature review on the management of diabetic foot ulcer

Diabetic foot ulcer (DFU) is the most costly and devastating complication of diabetes mellitus, which affect 15% of diabetic patients during their lifetime. Based on National Institute for Health and Clinical Excellence strategies, early effective management of DFU can reduce the severity of complications such as preventable amputations and possible mortality, and also can improve overall quality of life. The management of DFU should be optimized by using a multidisciplinary team, due to a holistic approach to wound management is required. Based on studies, blood sugar control, wound debridement, advanced dressings and offloading modalities should always be a part of DFU management. Furthermore, surgery to heal chronic ulcer and prevent recurrence should be considered as an essential component of management in some cases. Also, hyperbaric oxygen therapy, electrical stimulation, negative pressure wound therapy, bio-engineered skin and growth factors could be used as adjunct therapies for rapid healing of DFU. So, it’s suggested that with appropriate patient education encourages them to regular foot care in order to prevent DFU and its complications.

The management of diabetic foot ulcers through optimal off-loading: building consensus guidelines and practical recommendations to improve outcomes

BACKGROUND

We sought to develop a consensus statement for the use of off-loading in the management of diabetic foot ulcers (DFUs).

METHODS

A literature search of PubMed for evidence regarding off-loading of DFUs was initially conducted, followed by a meeting of authors on March 15, 2013, in Philadelphia, Pennsylvania, to draft consensus statements and recommendations using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to assess quality of evidence and develop strength of recommendations for each consensus statement.

RESULTS

Evidence is clear that adequate off-loading increases the likelihood of DFU healing and that increased clinician use of effective off-loading is necessary. Recommendations are included to guide clinicians on the optimal use of off-loading based on an initial comprehensive patient/wound assessment and the necessity to improve patient adherence with off-loading devices.

CONCLUSIONS

The likelihood of DFU healing is increased with off-loading adherence, and, current evidence favors the use of nonremovable casts or fixed ankle walking braces as optimum off-loading modalities. There currently exists a gap between what the evidence supports regarding the efficacy of DFU off-loading and what is performed in clinical practice despite expert consensus on the standard of care.

Offloading the diabetic and ischemic foot: solutions for the vascular specialist

For generations, the use of techniques to defer skin pressure and protect the lower-extremity wound has been a cardinal goal to achieve therapeutic success and healing. Choosing the appropriate postoperative offloading device or shoe is often difficult, as it is challenging to merge optimal mechanical protection with clinical realities and patient needs. The gold standard for offloading remains the total contact cast, yet it receives minimal utilization in the clinical setting. Other devices have shown benefit, including the removable cast walker, instant total contact cast, and depth inlay shoes, for preventative measures. Ultimately, any plantar, lower-extremity wound must receive some form of external pressure reduction to reach acceptable rates of healing. Future technologies will aid these measures by providing body-worn constant monitoring systems and more effective offloading via patient-specific exoskeletons. This review is a supplemental update on the available wound offloading modalities based on logic-driven research regarding pressure relief across the diabetic neuropathic or impaired perfusion foot.

Characteristics of diabetic foot ulcers in Western Sydney, Australia

BACKGROUND

Australia is ranked ninth of 39 countries in the Western Pacific region most affected by diabetes. Patients with diabetes are at high risk of developing foot ulcerations that can develop into non-healing wounds. Recent studies suggest that the lifetime risk of developing a diabetic foot ulcer is as high as 25%. Few studies have reported the prevalence of, risk factors and socioeconomic status associated with, diabetic foot ulcers in Australia. The aim of this study was to evaluate the characteristics of diabetic foot ulcers in a tertiary referral outpatient hospital setting in Western Sydney, Australia.

METHODS

From January-December 2011, a total of 195 outpatients with diabetes were retrospectively extracted for analysis from the Westmead Hospital's Foot Wound Clinic Registry. Data on demographics, socioeconomic status, co-morbidities, foot ulcer characteristics and treatment were recorded on a standardised form.

RESULTS

Demographics and physical characteristics were: 66.2% male, median age 67 years (IQR: 56-76), median body mass index (BMI) of 28 kg/m(2) (IQR: 25.2-34.1), 75.4% had peripheral neuropathy and the median postcode score for socioeconomic status was 996 (IQR: 897-1022). Diabetic foot ulcer characteristics were: median cross sectional area of 1.5 cm(2) (IQR: 0.5-7.0), median volume of 0.4 cm(3) (IQR: 0.11-3.0), 45.1% on the plantar aspect of the foot, 16.6% UT Wound Grade of 0C to 3C (with ischaemia) and 11.8% with a Grade 0D to 3D (with infection and ischaemia) and 25.6% with osteomyelitis. Five patients required an amputation: 1 major and 4 minor amputations.

CONCLUSIONS

In accordance with other international studies, foot ulcers are more likely to present on the plantar surface of the foot and largely affect overweight older males with a long standing history diabetes in our outpatient hospital in Western Sydney.

How Can I Maintain My Patient With Diabetes and History of Foot Ulcer in Remission?

Patients with diabetes and previous history of ulceration occupy the highest category of risk for reulceration and amputation. Annual recurrence rates of diabetic ulcerations have been reported as high as 34%, 61%, and 70% at 1, 3, and 5 years, respectively, with studies reporting 20% to 58% recurrence rate within 1 year. As the ever growing epidemic of diabetes expands globally, this sequelae of diabetic complication will continue to require increasing resources from the healthcare community to effectively manage. Recent data suggest that removal of preventative podiatric care from statewide reimbursement systems lead to significant and sustained increases in hospital admission (37%), charges (38%), length of stay (23%), and severe aggregate outcomes including amputation, sepsis and death (49%). The addition of comorbidities such as peripheral artery disease, poor nutrition, and non-adherence to preventive therapies not only increase a patient’s likelihood for ulcer recurrence, but also cost of care and certainty of hospital admission. Currently, numerous efforts, guidelines, and industry generated products exist to prolong remission from ulceration; however, the clinical science for treating this patient population calls for much more effort. Despite this, data continue to suggest to demonstrate that appropriate follow-up care, shoe and insole modification, and patient education play a central role in reducing reulceration and amputation. Novel modalities for offloading and wearable sensor technologies offer the advantage of round-the-clock, patient specific and active response healthcare. These have the potential to detect, or even prevent, many wounds before they begin.

A survey of offloading practices for diabetes-related plantar neuropathic foot ulcers

Background

Offloading is key to preventing or healing plantar neuropathic foot ulcers in diabetes. Total contact casts or walkers rendered irremovable are recommended in guidelines as first-line options for offloading, however the use of such devices has been found to be low. This study aimed to investigate offloading practices for diabetes-related plantar neuropathic ulcers.

Methods

An online survey of closed and open-ended questions was administered via SurveyMonkey®. Forty-one podiatrists experienced in high-risk foot practice, from 21 high-risk foot services around Australia, were approached to participate.

Results

The response rate was 88%. Participants reported using 21 modalities or combinations of modalities, for offloading this ulcer type. The most frequently used modalities under the forefoot and hallux were felt padding, followed by removable casts or walkers, then non-removable casts or walkers. Participants indicated that many factors were considered when selecting offloading modality, including: compliance, risk of adverse effects, psycho-social factors, restrictions on activities of daily living, work needs and features of the wound. The majority of participants (83%) considered non-removable casts or walkers to be the gold-standard for offloading this ulcer type, however they reported numerous, particularly patient-related, barriers to their use.

Conclusions

Selecting offloading for the management of foot ulceration is complex. Felt padding, not the gold-standard non-removable cast or walker, was reported as the most commonly selected modality for offloading plantar neuropathic ulceration. However, further evaluation of felt padding in high quality clinical trials is required to ascertain its effectiveness for ulcer healing.

The efficacy and safety of Grafix(®) for the treatment of chronic diabetic foot ulcers: results of a multi-centre, controlled, randomised, blinded, clinical trial

In a randomised, controlled study, we compared the efficacy of Grafix^®, a human viable wound matrix (hVWM) (N = 50), to standard wound care (n = 47) to heal diabetic foot ulcers (DFUs). The primary endpoint was the proportion of patients with complete wound closure by 12 weeks. Secondary endpoints included the time to wound closure, adverse events and wound closure in the crossover phase. The proportion of patients who achieved complete wound closure was significantly higher in patients who received Grafix (62%) compared with controls (21%, P = 0·0001). The median time to healing was 42 days in Grafix patients compared with 69·5 days in controls (P = 0·019). There were fewer Grafix patients with adverse events (44% versus 66%, P = 0·031) and fewer Grafix patients with wound‐related infections (18% versus 36·2%, P = 0·044). Among the study subjects that healed, ulcers remained closed in 82·1% of patients (23 of 28 patients) in the Grafix group versus 70% (7 of 10 patients) in the control group (P = 0·419). Treatment with Grafix significantly improved DFU healing compared with standard wound therapy. Importantly, Grafix also reduced DFU‐related complications. The results of this well‐controlled study showed that Grafix is a safe and more effective therapy for treating DFUs than standard wound therapy.

Diabetic foot ulcer: an evidence-based treatment update

BACKGROUND

Diabetic foot ulcers (DFUs) are extremely debilitating and difficult to treat. Multidisciplinary management, patient education, glucose control, debridement, offloading, infection control, and adequate perfusion are the mainstays of standard care endorsed by most practice guidelines. Adjunctive therapies represent new treatment modalities endorsed in recent years, though many lack significant high-powered studies to support their use as standard of care.

OBJECTIVE

This update intends to identify recent, exclusively high level, evidence-based evaluations of DFU therapies. Furthermore, it suggests a direction for future research.

METHODS

PubMed, Embase, Ovid Technologies, CINAHL, Cochrane, and Web of Science databases were systematically searched for recent systematic reviews published after 2004, and randomized controlled trials published in 2012-2013 that evaluated treatment modalities for DFUs. These papers are reviewed and the quality of available evidence is discussed.

RESULTS

A total of 34 studies met inclusion criteria. Studied therapies include debridement, off-loading, negative pressure therapy, dressings, topical therapies, hyperbaric oxygen therapy, growth factors, bioengineered skin substitutes, electrophysical therapy, and alternative therapy. Good-quality evidence is lacking to justify the use of many of these therapies, with the exception of standard care (offloading, debridement) and possibly negative pressure wound therapy.

LIMITATIONS

There is an overall lack of high-level evidence in new adjunctive management of DFU. Comparison of different treatment modalities is difficult, since existing studies are not standardized.

CONCLUSIONS

Many therapeutic modalities are available to treat DFU. Quality high-level evidence exists for standard care such as off-loading. Evidence for adjunctive therapies such as negative pressure wound therapy, skin substitutes, and platelet-derived growth factor can help guide adjunctive care but limitations exist in terms of evidence quality.

Low long-term risk of foot ulcer recurrence after nerve decompression in a diabetes neuropathy cohort

BACKGROUND

Use of nerve decompression in diabetic sensorimotor polyneuropathy is a controversial treatment characterized as being of unknown scientific effectiveness owing to lack of level I scientific studies.

METHODS

Herein, long-term follow-up data have been assembled on 65 diabetic patients with 75 legs having previous neuropathic foot ulcer and subsequent operative decompression of the common peroneal and tibial nerve branches in the anatomical fibro-osseous tunnels.

RESULTS

The cohort's previously reported low recurrence risk of less than 5% annually at a mean of 2.49 years of follow-up has persisted for an additional 3 years, and cumulative risk is now 2.6% per patient-year. Nine of 75 operated legs (12%) have developed an ulcer in 4,218 months (351 patient-years) of follow-up. Of the 53 contralateral legs without decompression, 16 (30%) have ulcerated, of which three have undergone an amputation. Fifty-nine percent of patients are known to be alive with intact feet a mean of 60 months after decompression.

CONCLUSIONS

The prospective, objective, statistically significant finding of a large, long-term diminution of diabetic foot ulcer recurrence risk after operative nerve decompression compares very favorably with the historical literature and the contralateral legs of this cohort, which had no decompression. This finding invites prospective randomized controlled studies for validation testing and reconsideration of the frequency and contribution of unrecognized nerve entrapments in diabetic sensorimotor polyneuropathy and diabetic foot complications.

Randomised clinical trial to compare total contact casts, healing sandals and a shear-reducing removable boot to heal diabetic foot ulcers

The objective of this study was to evaluate the efficacy of three off-loading techniques to heal diabetic foot wounds: total contact casts (TCCs), healing sandals (HSs) and a removable boot with a shear-reducing foot bed (SRB). This was a 12-week, single-blinded randomised clinical trial with three parallel treatment groups of adults with diabetes and a foot ulcer (n = 73). Ulcer healing was defined as full reepithelialisation with no drainage. Diabetic patients with grade UT1A or UT2A forefoot ulcers on the sole of the foot were enrolled. Patients with malignancy, immune-compromising diseases, severe peripheral vascular disease (ankle-brachial index < 0·60 or transcutaneous oxygen < 25 mm/Hg), alcohol or substance abuse within 6 months, untreated osteomyelitis or Charcot arthropathy with residual deformity that would not fit the HS or boot were excluded. In the intent-to-treat analysis, significantly higher proportion of patients were healed in the TCC group (69·6%) compared to those treated with the SRB (22·2%, P < 0·05). There was no difference in the rate of healed ulcers in the HS (44·5%) and TCC groups. Ulcers in the TCC group healed faster than those in the HS group (5·4 ± 2·9 versus 8·9 ± 3·5 weeks, P < 0·02). However, there was no difference in the time to healing in the TCC and SRB groups (6·7 ± 4·3 weeks, P = 0·28). Patients who used HS were significantly more active (4022 ± 4652 steps per day, P < 0·05) than those treated with TCCs (1447 ± 1310) or SRB (1404 ± 1234). It is concluded that patients treated with TCCs had the highest proportion of healed wounds and fastest healing time. The novel shear-reducing walker had the lowest healing and highest rate of attrition during the study.

Offloading of the diabetic foot: orthotic and pedorthic strategies

The diabetic foot is more susceptible than the non-diabetic foot to collapse. This frequently leads to bony prominences followed by ulceration. Offloading of areas of increased pressure is paramount to ulcer prevention and healing. Several devices and accommodations can aid practitioners in saving patients' extremities and allow them to ambulate. A team approach works best, and patient education is a must. Regular assessment and modifications are required for longevity of each device. In this article, different therapeutic options are detailed. A variety of presentations and situations are discussed and the authors' best tips for avoiding complications are offered.