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Roy AP, Jana S, Das H, Das P, Chakraborty B, Mukherjee P, Datta P, Mondal S, Kundu B, Nandi SK. Stimulated Full-Thickness Cutaneous Wound Healing with Bioactive Dressings of Zinc and Cobalt Ion-Doped Bioactive Glass-Coated Eggshell Membranes in a Diabetic Rabbit Model. ACS Biomater Sci Eng 2024. [PMID: 38826128 DOI: 10.1021/acsbiomaterials.4c00691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Eggshell membrane-based biomedical applications have recently received great attention for their wound-healing properties. However, there are limited studies on diabetic wound healing. In this regard, we devised four types of composite eggshell membrane mats with nanoscale coatings of bioactive glass/Zn/Co-doped bioactive glass (ESM + BAG, ESM + ZnBAG, ESM + CoBAG, and ESM + ZnCoBAG) as wound-dressing materials for chronic nonhealing diabetic wounds. A detailed study of the physicochemical properties of the mats was conducted. In vitro studies demonstrated cytocompatibility and viability of human dermal fibroblasts on all four types of mats. The cells also attached finely on the mats with the help of cellular extensions, as evident from scanning electron microscopy (SEM) and rhodamine-phalloidin and Hoechst 33342 staining of cellular components. Endowed with bioactive properties, these mats influenced all aspects of full-thickness skin wound healing in diabetic animal model studies. All of the mats, especially the ESM + ZnCoBAG mat, showed the earliest wound closure, effective renewal, and restructuring of the extracellular matrix in terms of an accurate and timely accumulation of collagen, elastin, and reticulin fibers. Hydroxyproline and sulfated glycosaminoglycans were significantly (p < 0.01, p < 0.05) higher in ESM-ZnCoBAG-treated wounds in comparison to ESM-BAG-treated wounds, which suggests that these newly developed mats have potential as an affordable diabetic wound care solution in biomedical research.
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Affiliation(s)
- Arka Pravo Roy
- Department of Veterinary Surgery and Radiology, West Bengal University of Animal and Fishery Sciences, Kolkata 700037, India
| | - Sonali Jana
- Department of Veterinary Physiology, West Bengal University of Animal and Fishery Sciences, Kolkata 700037, India
| | - Himanka Das
- Bioceramics and Coating Division, CSIR-Central Glass and Ceramic Research Institute, Kolkata 700032, India
| | - Pratik Das
- Department of Veterinary Surgery and Radiology, West Bengal University of Animal and Fishery Sciences, Kolkata 700037, India
| | - Bijayashree Chakraborty
- Department of Veterinary Surgery and Radiology, West Bengal University of Animal and Fishery Sciences, Kolkata 700037, India
| | - Prasenjit Mukherjee
- Department of Veterinary Clinical Complex, West Bengal University of Animal and Fishery Sciences, Kolkata 700037, India
| | - Pradyot Datta
- Bioceramics and Coating Division, CSIR-Central Glass and Ceramic Research Institute, Kolkata 700032, India
| | - Samiran Mondal
- Department of Veterinary Pathology, West Bengal University of Animal and Fishery Sciences, Kolkata 700037, India
| | - Biswanath Kundu
- Bioceramics and Coating Division, CSIR-Central Glass and Ceramic Research Institute, Kolkata 700032, India
| | - Samit Kumar Nandi
- Department of Veterinary Surgery and Radiology, West Bengal University of Animal and Fishery Sciences, Kolkata 700037, India
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Castro-Martins P, Marques A, Coelho L, Vaz M, Baptista JS. In-shoe plantar pressure measurement technologies for the diabetic foot: A systematic review. Heliyon 2024; 10:e29672. [PMID: 38699042 PMCID: PMC11064085 DOI: 10.1016/j.heliyon.2024.e29672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 05/05/2024] Open
Abstract
Introduction Loss of cutaneous protective sensation and high plantar pressures increase the risk for diabetic foot patients. Trauma and ulceration are imminent threats, making assessment and monitoring essential. This systematic review aims to identify systems and technologies for measuring in-shoe plantar pressures, focusing on the at-risk diabetic foot population. Methods A systematic search was conducted across four electronic databases (Scopus, Web of Science, PubMed, Oxford Journals) using PRISMA methodology, covering articles published in English from 1979 to 2024. Only studies addressing systems or sensors exclusively measuring plantar pressures inside the shoe were included. Results A total of 87 studies using commercially available devices and 45 articles proposing new systems or sensors were reviewed. The prevailing market offerings consist mainly of instrumented insoles. Emerging technologies under development often feature configurations with four, six or eight resistive sensors strategically placed within removable insoles. Despite some variability due to the inherent heterogeneity of human gait, these devices assess plantar pressure, although they present significant differences between them in measurement results. Individuals with diabetic foot conditions appears exhibit elevated plantar pressures, with reported peak pressures reaching approximately 1000 kPa. The results also showed significant differences between the diabetic and non-diabetic groups. Conclusion Instrumented insoles, particularly those incorporating resistive sensor technology, dominate the field. Systems employing eight sensors at critical locations represent a pragmatic approach, although market options extend to systems with up to 960 sensors. Differences between devices can be a critical factor in measurement and highlights the importance of individualized patient assessment using consistent measurement devices.
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Affiliation(s)
- Pedro Castro-Martins
- CIETI, ISEP, Polytechnic of Porto, Portugal
- Faculty of Engineering, University of Porto, Portugal
| | - Arcelina Marques
- CIETI, ISEP, Polytechnic of Porto, Portugal
- Institute for Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Luís Coelho
- CIETI, ISEP, Polytechnic of Porto, Portugal
- INESC-TEC, Centre for Robotics in Industry and Intelligent Systems, Porto, Portugal
| | - Mário Vaz
- Faculty of Engineering, University of Porto, Portugal
- Institute for Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
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Lockhart M, Dinneen SF, O'Keeffe DT. Plantar pressure measurement in diabetic foot disease: A scoping review. J Diabetes Investig 2024. [PMID: 38634342 DOI: 10.1111/jdi.14215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 04/19/2024] Open
Abstract
AIMS/INTRODUCTION Patients with a healed diabetic foot ulcer (DFU) have a 40% risk of ulcer recurrence within a year. New and effective measures to prevent DFU recurrence are essential. We aimed to highlight emerging trends and future research opportunities in the use of plantar pressure measurement to prevent DFU recurrence. MATERIALS AND METHODS Our scoping review protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis - Scoping Review protocol. Peer-reviewed, English-language papers were included that addressed both plantar pressure measurement and diabetic foot disease, either as primary studies that have advanced the field or as review papers that provide summaries and/or opinion on the field as a whole, as well as specific papers that provide guidelines for future research and advancement in the field. RESULTS A total of 24 eligible publications were identified in a literature search using PubMed. A further 36 eligible studies were included after searching the references sections of these publications, leaving a total of 60 publications included in this scoping review. CONCLUSIONS Plantar pressure measurement can and will play a major role in the prevention of DFU. There is already a strong, albeit limited, evidence base in place to prove its benefit in reducing DFU recurrence. More research is required in larger populations, using remote monitoring in real-world settings, and with improved technology.
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Affiliation(s)
- Michael Lockhart
- Center for Endocrinology, Diabetes and Metabolism, Galway University Hospitals, Galway, Ireland
- Health Innovation via Engineering (HIVE) Laboratory, Lambe Institute, University of Galway, Galway, Ireland
| | - Sean F Dinneen
- Center for Endocrinology, Diabetes and Metabolism, Galway University Hospitals, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Derek T O'Keeffe
- Center for Endocrinology, Diabetes and Metabolism, Galway University Hospitals, Galway, Ireland
- Health Innovation via Engineering (HIVE) Laboratory, Lambe Institute, University of Galway, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
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Răducu L, Moraru OE, Gheoca-Mutu DE, Peligrad T, Țigăran AE, Abu-Baker A, Ion DE, Ursuț BM, Jecan CR, Avino A. Confronting a New Challenge in Plastic Surgery: MDR Infections in Patients with Chronic Wounds. Life (Basel) 2024; 14:444. [PMID: 38672715 PMCID: PMC11050788 DOI: 10.3390/life14040444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The presence of a wound can be anywhere from non-problematic to life-threatening on a severity spectrum, with bacterial infection and resistance playing a major role in the development of chronicity, delaying wound healing. Wound colonization with multiple organisms and the limited number of effective antibiotics place a heavy burden on the healthcare system, with patients going through multiple surgeries during a prolonged hospitalization time. By analyzing the resistance patterns of pluri-bacterial populations and the approach used in managing complex cases, we aim to improve the protocols applied in caring for chronic wounds in our practice and share our experiences and observations. METHODS We designed a retrospective study on 212 diabetic and non-diabetic patients, aiming to evaluate the course of chronic wound treatment in our practice. We focused on the impact that MDR bacteria and diabetes have on surgical outcomes and their role in the healing process. RESULTS Patients who received empiric antibiotic therapy before being admitted eventually presented with multiple MDR bacteria compared to those who did not receive antibiotics (p = 0.014). The presence of at least one MDR bacteria in the wound bed was associated with ulcers reaching bone (p = 0.02) and was positively correlated with the number of surgeries performed (p < 0.001). Diabetes played a significant role in surgery-related complications (p = 0.02) and hospitalization time (p < 0.001). CONCLUSIONS Proper management of chronic wounds requires a comprehensive, multidisciplinary approach and a thorough understanding of antibiotic usage. To address this need, we have developed and implemented a chronic wound treatment protocol in our clinic, with the goal of discharging patients once their ulcers have been treated and closed. A key summary of the protocol presented is to reduce the incidence of MDR bacteria and improve the patient's quality of life.
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Affiliation(s)
- Laura Răducu
- Discipline of Plastic Surgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.R.); (C.-R.J.); (A.A.)
- Department of Plastic and Reconstructive Surgery, “Prof. Dr. Agrippa Ionescu” Emergency Clinical Hospital, 011356 Bucharest, Romania; (D.-E.G.-M.); (A.-E.Ț.); (A.A.-B.); (D.-E.I.)
| | - Oriana Elena Moraru
- Discipline of Cardiovascular Surgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Vascular Surgery, “Prof. Dr. Agrippa Ionescu” Emergency Clinical Hospital, 011356 Bucharest, Romania
| | - Daniela-Elena Gheoca-Mutu
- Department of Plastic and Reconstructive Surgery, “Prof. Dr. Agrippa Ionescu” Emergency Clinical Hospital, 011356 Bucharest, Romania; (D.-E.G.-M.); (A.-E.Ț.); (A.A.-B.); (D.-E.I.)
- Discipline of Anatomy, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Teodora Peligrad
- Department of Plastic and Reconstructive Surgery, “Prof. Dr. Agrippa Ionescu” Emergency Clinical Hospital, 011356 Bucharest, Romania; (D.-E.G.-M.); (A.-E.Ț.); (A.A.-B.); (D.-E.I.)
| | - Andrada-Elena Țigăran
- Department of Plastic and Reconstructive Surgery, “Prof. Dr. Agrippa Ionescu” Emergency Clinical Hospital, 011356 Bucharest, Romania; (D.-E.G.-M.); (A.-E.Ț.); (A.A.-B.); (D.-E.I.)
| | - Abdalah Abu-Baker
- Department of Plastic and Reconstructive Surgery, “Prof. Dr. Agrippa Ionescu” Emergency Clinical Hospital, 011356 Bucharest, Romania; (D.-E.G.-M.); (A.-E.Ț.); (A.A.-B.); (D.-E.I.)
- Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Daniela-Elena Ion
- Department of Plastic and Reconstructive Surgery, “Prof. Dr. Agrippa Ionescu” Emergency Clinical Hospital, 011356 Bucharest, Romania; (D.-E.G.-M.); (A.-E.Ț.); (A.A.-B.); (D.-E.I.)
| | - Bogdan Mihai Ursuț
- Discipline of Anatomy, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of General Surgery, “Prof. Dr. Agrippa Ionescu” Emergency Clinical Hospital, 011356 Bucharest, Romania
| | - Cristian-Radu Jecan
- Discipline of Plastic Surgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.R.); (C.-R.J.); (A.A.)
- Department of Plastic and Reconstructive Surgery, “Prof. Dr. Agrippa Ionescu” Emergency Clinical Hospital, 011356 Bucharest, Romania; (D.-E.G.-M.); (A.-E.Ț.); (A.A.-B.); (D.-E.I.)
| | - Adelaida Avino
- Discipline of Plastic Surgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.R.); (C.-R.J.); (A.A.)
- Department of Plastic and Reconstructive Surgery, “Prof. Dr. Agrippa Ionescu” Emergency Clinical Hospital, 011356 Bucharest, Romania; (D.-E.G.-M.); (A.-E.Ț.); (A.A.-B.); (D.-E.I.)
- Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
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Castro-Martins P, Marques A, Coelho L, Vaz M, Costa JT. Plantar pressure thresholds as a strategy to prevent diabetic foot ulcers: A systematic review. Heliyon 2024; 10:e26161. [PMID: 38390156 PMCID: PMC10882031 DOI: 10.1016/j.heliyon.2024.e26161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/22/2023] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Background The development of ulcers in the plantar region of the diabetic foot originates mainly from sites subjected to high pressure. The monitoring of these events using maximum allowable pressure thresholds is a fundamental procedure in the prevention of ulceration and its recurrence. Objective The aim of this review was to identify data in the literature that reveal an objective threshold of plantar pressure in the diabetic foot, where pressure is classified as promoting ulceration. The aim is not to determine the best and only pressure threshold for ulceration, but rather to clarify the threshold values most used in clinical practice and research, also considering the devices used and possible applications for offloading plantar pressure. Design A systematic review. Methods The search was performed in three electronic databases, by the PRISMA methodology, for studies that used a pressure threshold to minimize the risk of ulceration in the diabetic foot. The selected studies were subjected to eligibility criteria. Results Twenty-six studies were included in this review. Seven thresholds were identified, five of which are intended for the inside of the shoe: a threshold of average peak pressure of 200 kPa; 25 % and 40-80 % reduction from initial baseline pressure; 32-35 mm Hg for a capillary perfusion pressure; and a matrix of thresholds based on patient risk, shoe size and foot region. Two other thresholds are intended for the barefoot, 450 and 750 kPa. The threshold of 200 kPa of pressure inside the shoe is the most agreed upon among the studies. Regarding the prevention of ulceration and its recurrence, the efficacy of the proposed threshold matrix and the threshold of reducing baseline pressure by 40-80 % has not yet been evaluated, and the evidence for the remaining thresholds still needs further studies. Conclusions Some heterogeneity was found in the studies, especially regarding the measurement systems used, the number of regions of interest and the number of steps to be considered for the threshold. Even so, this review reveals the way forward to obtain a threshold indicative of an effective steppingstone in the prevention of diabetic foot ulcer.
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Affiliation(s)
- Pedro Castro-Martins
- CIETI, ISEP, Polytechnic of Porto, Portugal
- Faculty of Engineering, University of Porto, Portugal
| | - Arcelina Marques
- CIETI, ISEP, Polytechnic of Porto, Portugal
- Institute for Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Luís Coelho
- CIETI, ISEP, Polytechnic of Porto, Portugal
- INESC-TEC, Centre for Robotics in Industry and Intelligent Systems, Porto, Portugal
| | - Mário Vaz
- Faculty of Engineering, University of Porto, Portugal
- Institute for Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - José Torres Costa
- Faculty of Engineering, University of Porto, Portugal
- Faculty of Medicine, University of Porto, Portugal
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Hancox JE, Hilton C, Gray K, Game F, Vedhara K. Adherence to limiting weight-bearing activity in patients with diabetic foot ulcers: A qualitative study. Int Wound J 2023; 20:3945-3954. [PMID: 37312664 PMCID: PMC10681470 DOI: 10.1111/iwj.14282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 06/01/2023] [Indexed: 06/15/2023] Open
Abstract
Patients with diabetic foot ulcers are advised to limit weight-bearing activity for ulcers to heal. Patients often disregard this advice although the reasons are not yet fully understood. This study explored (1) patients' experiences of receiving the advice and (2) factors influencing adherence to the advice. Semi-structured interviews were conducted with 14 patients with diabetic foot ulcers. Interviews were transcribed and analysed using inductive thematic analysis. Advice regarding limiting weight-bearing activity was described by patients as directive, generic and conflicting with other priorities. Rapport, empathy and rationale supported receptivity to the advice. Barriers and facilitators to limiting weight-bearing activity included demands of daily living, enjoyment of exercise, sick/disabled identity and burden, depression, neuropathy/pain, health benefits, fear of negative consequences, positive feedback, practical support, weather and active/passive role in recovery. It is important that healthcare professionals pay attention to how limiting weight-bearing activity advice is communicated. We propose a more person-centred approach in which advice is tailored to individuals' specific needs with discussion around patient priorities and constraints.
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Affiliation(s)
- Jennie E. Hancox
- School of MedicineUniversity of NottinghamNottinghamUK
- Loughborough UniversityLoughboroughUK
| | | | - Katie Gray
- Derbyshire Community Health Services NHSBakewellUK
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation TrustDerbyUK
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Mohaddis M, Maqsood SA, Ago E, Singh S, Naim Z, Prasad S. Enhancing Functional Rehabilitation Through Orthotic Interventions for Foot and Ankle Conditions: A Narrative Review. Cureus 2023; 15:e49103. [PMID: 38024022 PMCID: PMC10659571 DOI: 10.7759/cureus.49103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 12/01/2023] Open
Abstract
Non-surgical, conservative approaches to foot and ankle conditions are of important consideration. Orthotics play a significant role in treating these conditions, preventing progression, and alleviating pressure on affected areas, thereby promoting normal gait. This article aims to assess the utility and effectiveness of various orthotic treatments in different clinical scenarios. We reviewed 27 peer-reviewed articles using electronic databases, employing keywords such as "orthoses," "orthotic treatment," "arthritis," "neuropathy," and "foot and ankle trauma." Studies conducted in recent decades have explored the effectiveness of orthoses in various conditions, including connective tissue disorders, tendon and ligament injuries, foot arthritis, neuropathic and inflammatory wounds, and sports-related recurrent injuries. Orthotic management has proven effective across diverse foot and ankle conditions. Integrating orthotic treatment with systemic approaches benefits patients with foot and ankle disorders. We believe this review can be utilised by clinicians in the management of foot and ankle disorders.
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Affiliation(s)
- Momin Mohaddis
- Trauma and Orthopaedics, Warrington and Halton Hospitals NHS Trust, Liverpool, GBR
| | - Saad A Maqsood
- Trauma and Orthopaedics, Warrington and Halton Hospitals NHS Trust, Liverpool, GBR
| | - Emmanuel Ago
- Trauma and Orthopaedics, Warrington and Halton Hospitals NHS Trust, Liverpool, GBR
| | - Sushmit Singh
- Trauma and Orthopaedics, Warrington and Halton Hospitals NHS Trust, Liverpool, GBR
| | - Zahra Naim
- General Practice, Shadan Institute of Medical Sciences, Hyderabad, IND
| | - Seema Prasad
- Trauma and Orthopaedics, Warrington and Halton Hospitals NHS Trust, Liverpool, GBR
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Anwander H, Vonwyl D, Hecht V, Tannast M, Kurze C, Krause F. Risk Factors for Failure After Surgery in Patients With Diabetic Foot Syndrome. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231182656. [PMID: 37435393 PMCID: PMC10331347 DOI: 10.1177/24730114231182656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background In the present study, we aimed to identify risk factors for failure (defined as reoperation within 60 days) after debridement or amputation at the lower extremity in patients with diabetic foot syndrome and to develop a model using the significant risk factors to predict the success rate at different levels of amputation. Methods Between September 2012 and November 2016, we performed a prospective observational cohort study of 174 surgeries in 105 patients with diabetic foot syndrome. In all patients, debridement or the level of amputation, need for reoperation, time to reoperation, and potential risk factors were assessed. A cox regression analysis, dependent on the level of amputation, with the endpoint reoperation within 60 days defined as failure and a predictive model for the significant risk factors were conducted. Results We identified the following 5 independent risk factors: More than 1 ulcer (hazard ratio [HR] 3.8), peripheral artery disease (PAD, HR 3.1), C-reactive protein >100 mg/L (HR 2.9), diabetic peripheral neuropathy (HR 2.9), and nonpalpable foot pulses (HR 2.7) are the 5 independent risk factors for failure, which were identified. Patients with no or 1 risk factor have a high success rate independent of the level of amputation. A patient with up to 2 risk factors undergoing debridement will achieve a success rate of <60%. However, a patient with 3 risk factors undergoing debridement will need further surgery in >80%. In patients with 4 risk factors a transmetatarsal amputation and in patients with 5 risk factors a lower leg amputation is needed for a success rate >50%. Conclusion Reoperation for diabetic foot syndrome occurs in 1 of 4 patients. Risk factors include presence of more than 1 ulcer, PAD, CRP > 100, peripheral neuropathy, and nonpalpable foot pulses. The more risk factors are present, the lower the success rate at a certain level of amputation. Level of Evidence Level II, prospective observational cohort study.
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Affiliation(s)
- Helen Anwander
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Vonwyl
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Verena Hecht
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Christophe Kurze
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Krause
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Footwear and insole design parameters to prevent occurrence and recurrence of neuropathic plantar forefoot ulcers in patients with diabetes: a series of N-of-1 trial study protocol. Trials 2022; 23:1017. [PMID: 36527100 PMCID: PMC9755781 DOI: 10.1186/s13063-022-06968-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Foot complications occur in conjunction with poorly controlled diabetes. Plantar forefoot ulceration contributes to partial amputation in unstable diabetics, and the risk increases with concomitant neuropathy. Reducing peak plantar forefoot pressure reduces ulcer occurrence and recurrence. Footwear and insoles are used to offload the neuropathic foot, but the success of offloading is dependent on patient adherence. This study aims to determine which design and modification features of footwear and insoles improve forefoot plantar pressure offloading and adherence in people with diabetes and neuropathy. METHODS This study, involving a series of N-of-1 trials, included 21 participants who had a history of neuropathic plantar forefoot ulcers. Participants were recruited from two public hospitals and one private podiatry clinic in Sydney, New South Wales, Australia. This trial is non-randomised and unblinded. Participants will be recruited from three sites, including two high-risk foot services and a private podiatry clinic in Sydney, Australia. Mobilemat™ and F-Scan® plantar pressure mapping systems by TekScan® (Boston, USA) will be used to measure barefoot and in-shoe plantar pressures. Participants' self-reports will be used to quantify the wearing period over a certain period of between 2 and 4 weeks during the trial. Participant preference toward footwear, insole design and quality-of-life-related information will be collected and analysed. The descriptive and inferential statistical analyses will be performed using IBM SPSS Statistics (version 27). And the software NVivo (version 12) will be utilised for the qualitative data analysis. DISCUSSION This is the first trial assessing footwear and insole interventions in people with diabetes by using a series of N-of-1 trials. Reporting self-declared wearing periods and participants' preferences on footwear style and aesthetics are the important approaches for this trial. Patient-centric device designs are the key to therapeutic outcomes, and this study is designed with that strategy in mind. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000699965p. Registered on June 23, 2020.
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Wang X, Yuan CX, Xu B, Yu Z. Diabetic foot ulcers: Classification, risk factors and management. World J Diabetes 2022; 13:1049-1065. [PMID: 36578871 PMCID: PMC9791567 DOI: 10.4239/wjd.v13.i12.1049] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/18/2022] [Accepted: 11/18/2022] [Indexed: 12/15/2022] Open
Abstract
Diabetic foot ulceration is a devastating complication of diabetes that is associated with infection, amputation, and death, and is affecting increasing numbers of patients with diabetes mellitus. The pathogenesis of foot ulcers is complex, and different factors play major roles in different stages. The refractory nature of foot ulcer is reflected in that even after healing there is still a high recurrence rate and amputation rate, which means that management and nursing plans need to be considered carefully. The importance of establishment of measures for prevention and management of DFU has been emphasized. Therefore, a validated and appropriate DFU classification matching the progression is necessary for clinical diagnosis and management. In the first part of this review, we list several commonly used classification systems and describe their application conditions, scope, strengths, and limitations; in the second part, we briefly introduce the common risk factors for DFU, such as neuropathy, peripheral artery disease, foot deformities, diabetes complications, and obesity. Focusing on the relationship between the risk factors and DFU progression may facilitate prevention and timely management; in the last part, we emphasize the importance of preventive education, characterize several of the most frequently used management approaches, including glycemic control, exercise, offloading, and infection control, and call for taking into account and weighing the quality of life during the formulation of treatment plans. Multidisciplinary intervention and management of diabetic foot ulcers (DFUs) based on the effective and systematic combination of these three components will contribute to the prevention and treatment of DFUs, and improve their prognosis.
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Affiliation(s)
- Xuan Wang
- Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Chong-Xi Yuan
- Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Bin Xu
- Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Zhi Yu
- Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
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Yang L, Rong GC, Wu QN. Diabetic foot ulcer: Challenges and future. World J Diabetes 2022; 13:1014-1034. [PMID: 36578870 PMCID: PMC9791573 DOI: 10.4239/wjd.v13.i12.1014] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/07/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022] Open
Abstract
Diabetic foot ulcers (DFUs) have become one of the important causes of mortality and morbidity in patients with diabetes, and they are also a common cause of hospitalization, which places a heavy burden on patients and society. The prevention and treatment of DFUs requires multidisciplinary management. By controlling various risk factors, such as blood glucose levels, blood pressure, lipid levels and smoking cessation, local management of DFUs should be strengthened, such as debridement, dressing, revascularization, stem cell decompression and oxygen therapy. If necessary, systemic anti-infection treatment should be administered. We reviewed the progress in the clinical practice of treating DFUs in recent years, such as revascularization, wound repair, offloading, stem cell transplantation, and anti-infection treatment. We also summarized and prospectively analyzed some new technologies and measurements used in the treatment of DFUs and noted the future challenges and directions for the development of DFU treatments.
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Affiliation(s)
- Li Yang
- Department of Endocrinology, Dazu Hospital of Chongqing Medical University, The People's Hospital of Dazu, Chongqing 402360, China
| | - Gui-Chuan Rong
- Department of Gynaecology, Dazu Hospital of Chongqing Medical University, The People's Hospital of Dazu, Chongqing 402360, China
| | - Qi-Nan Wu
- Department of Endocrinology, Dazu Hospital of Chongqing Medical University, The People's Hospital of Dazu, Chongqing 402360, China
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12
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Mantri Y, Mishra A, Anderson CA, Jokerst JV. Photoacoustic imaging to monitor outcomes during hyperbaric oxygen therapy: validation in a small cohort and case study in a bilateral chronic ischemic wound. BIOMEDICAL OPTICS EXPRESS 2022; 13:5683-5694. [PMID: 36733747 PMCID: PMC9872873 DOI: 10.1364/boe.472568] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 06/18/2023]
Abstract
Hyperbaric oxygen therapy (HBO2) is a common therapeutic modality that drives oxygen into hypoxic tissue to promote healing. Here, ten patients undergoing HBO2 underwent PA oximetry of the left radial artery and forearm pre- and post-HBO2; this cohort validated the use of PA imaging in HBO2. There was a significant increase in radial artery oxygenation after HBO2 (p = 0.002) in the validation cohort. We also include a case study: a non-diabetic male in his 50s (HB 010) presenting with bilateral ischemic and gangrenous wounds. HB 010 showed higher perfusion and oxygen saturation on the right foot than the left after HBO2 which correlated with independent surgical observations. Imaging assisted with limb salvage treatment. Hence, this work shows that PA imaging can measure changes in arterial oxygen saturation due to HBO2; it can also produce 3D maps of tissue oxygenation and evaluate response to therapy during HBO2.
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Affiliation(s)
- Yash Mantri
- Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
| | - Aditya Mishra
- Materials Science Program, University of California San Diego, La Jolla, CA, USA
| | - Caesar A. Anderson
- Department of Emergency Medicine, Hyperbaric and Wound Healing Center, University of California San Diego, Encinitas, CA, USA
| | - Jesse V. Jokerst
- Materials Science Program, University of California San Diego, La Jolla, CA, USA
- Department of Nanoengineering, University of California San Diego, La Jolla, CA, USA
- Department of Radiology, University of California San Diego, La Jolla, CA, USA
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13
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Maharana P, Sonawane J, Belehalli P, Ananthasuresh GK. Self-offloading therapeutic footwear using compliant snap-through arches. WEARABLE TECHNOLOGIES 2022; 3:e7. [PMID: 38486896 PMCID: PMC10936371 DOI: 10.1017/wtc.2022.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/09/2022] [Accepted: 03/06/2022] [Indexed: 03/17/2024]
Abstract
In diabetic peripheral neuropathy, offloading high-plantar-pressure areas using statically offloaded customized insoles or expensive sensors and actuators are commonly-followed treatment procedures. In this article, we propose the concept of dynamically self-offloading therapeutic footwear that operates mechanically without using sensors and actuators. We achieve this by using an array of snapping arches. When a load higher than a bespoke value is applied, these arches enter negative-stiffness regime and offload the high-pressure region by snapping to a different shape. They again return to their initial shape when the load disappears. Thus, they serve as both sensors and actuators that get actuated by person's body weight. We present an analytical method to compute the switching load and the switchback time of such arches and use them to customize the footwear according to the person's body weight, gait speed, and foot size. We identify the high-pressure regions from the clinical data and place the arches such that these high-pressure regions get dynamically offloaded, and the pressure gets redistributed to other regions. We considered 200 kPa as a limiting pressure to prevent the prolonged effects of high plantar pressure. To check the efficacy of the concept, a complete 3D-printed prototype made of thermoplastic polyurethane was tested and compared with barefoot and in-shoe plantar pressure for subjects recruited at a clinical facility. We notice that the self-offloading insole shows the plantar pressure reduction at all the foot regions, and significant offloading of 57% is observed at the forefoot region.
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Affiliation(s)
| | - Jyoti Sonawane
- Mechanical Engineering, Indian Institute of Science, Bengaluru, India
| | - Pavan Belehalli
- Department of Podiatry, Karnataka Institute of Endocrinology and Research, Bengaluru, India
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14
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Yu Q, Qiao GH, Wang M, Yu L, Sun Y, Shi H, Ma TL. Stem Cell-Based Therapy for Diabetic Foot Ulcers. Front Cell Dev Biol 2022; 10:812262. [PMID: 35178389 PMCID: PMC8844366 DOI: 10.3389/fcell.2022.812262] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/04/2022] [Indexed: 02/06/2023] Open
Abstract
Diabetic foot ulcer has become a worldwide clinical medical challenge as traditional treatments are not effective enough to reduce the amputation rate. Therefore, it is of great social significance to deeply study the pathogenesis and biological characteristics of the diabetic foot, explore new treatment strategies and promote their application. Stem cell-based therapy holds tremendous promise in the field of regenerative medicine, and its mechanisms include promoting angiogenesis, ameliorating neuroischemia and inflammation, and promoting collagen deposition. Studying the specific molecular mechanisms of stem cell therapy for diabetic foot has an important role and practical clinical significance in maximizing the repair properties of stem cells. In addition, effective application modalities are also crucial in order to improve the survival and viability of stem cells at the wound site. In this paper, we reviewed the specific molecular mechanisms of stem cell therapy for diabetic foot and the extended applications of stem cells in recent years, with the aim of contributing to the development of stem cell-based therapy in the repair of diabetic foot ulcers.
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Affiliation(s)
- Qian Yu
- Department of Hepatology, Songjiang Hospital Affiliated to Nanjing Medical University, Shanghai, China
| | - Guo-Hong Qiao
- Department of Clinical Laboratory, The Affiliated Yixing Hospital of Jiangsu University, Yixing, China
| | - Min Wang
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, Institute of Stem Cell, School of Medicine, Jiangsu University, Zhenjiang, China
| | - Li Yu
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, Institute of Stem Cell, School of Medicine, Jiangsu University, Zhenjiang, China
| | - Yaoxiang Sun
- Department of Clinical Laboratory, The Affiliated Yixing Hospital of Jiangsu University, Yixing, China
| | - Hui Shi
- Department of Clinical Laboratory, The Affiliated Yixing Hospital of Jiangsu University, Yixing, China.,Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, Institute of Stem Cell, School of Medicine, Jiangsu University, Zhenjiang, China
| | - Tie-Liang Ma
- Department of Clinical Laboratory, The Affiliated Yixing Hospital of Jiangsu University, Yixing, China
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15
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Zhang X, Wang H, Du C, Fan X, Cui L, Chen H, Deng F, Tong Q, He M, Yang M, Tan X, Li L, Liang Z, Chen Y, Chen D, Armstrong DG, Deng W. Custom-Molded Offloading Footwear Effectively Prevents Recurrence and Amputation, and Lowers Mortality Rates in High-Risk Diabetic Foot Patients: A Multicenter, Prospective Observational Study. Diabetes Metab Syndr Obes 2022; 15:103-109. [PMID: 35046681 PMCID: PMC8759996 DOI: 10.2147/dmso.s341364] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 12/21/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Recurrence of high-risk diabetic feet, after wound, healing is a common challenge among diabetic patients. Continuous use of an offloading device significantly prevents recurrence of high-risk diabetic feet, although patient adherence is imperative to ensuring this therapy's clinical efficacy. In this study, we explored clinical outcomes of patients with a high-risk diabetic foot who had been prescribed with custom-molded offloading footwear under different adherence conditions. METHODS A total of 48 patients (17 females and 31 males) with high-risk diabetic feet, who had been with prescribed offloading footwear in 13 medical centers across 4 cities, were enrolled in the current study. The patients were assigned into either continuous offloading therapy (COT, n = 31) or interrupted offloading therapy (IOT, n = 17) groups, according to their adherence to the therapy. All patients were followed up monthly, and differences in recurrence, amputation, and deaths between the groups were analyzed at 4 months after therapy. RESULTS Forty-eight patients met our inclusion criteria and were therefore included in the final analysis. Among them, 31 were stratified into the COT group and adhered to offloading therapy throughout the study period, whereas 17 were grouped as IOT and exhibited interrupted adherence to offloading therapy. We found statistically significant differences in recurrence rates (0 vs 38.46%, p < 0.01), amputation (0 vs 11.76%, p < 0.01), and deaths (0% vs 5.88%, p < 0.01) between the groups during follow-up. CONCLUSION Patients' adherence is imperative to efficacy of custom-molded offloading footwear during treatment of high-risk diabetic foot. Further studies are needed to elucidate the role of improved design of the offloading device and the need for enhanced patient education for improved adherence.
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Affiliation(s)
- Xi Zhang
- Department of Endocrinology, Chongqing University Central Hospital, Chongqing University, Chongqing, People’s Republic of China
| | - Hongyan Wang
- Department of Endocrinology, Chongqing University Central Hospital, Chongqing University, Chongqing, People’s Republic of China
| | - Chenzhen Du
- Department of Endocrinology, Chongqing University Central Hospital, Chongqing University, Chongqing, People’s Republic of China
| | - Xiaoyun Fan
- Department of Endocrinology, Hospital for Occupational Diseases of Chongqing, Chongqing, People’s Republic of China
| | - Long Cui
- Department of Endocrinology, Armed Police Hospital of Chongqing, Chongqing, People’s Republic of China
| | - Heming Chen
- Department of Endocrinology, Ankang Central Hospital, Ankang, Shaanxi, People’s Republic of China
| | - Fang Deng
- Department of Endocrinology, Chongqing Southwest Hospital, Chongqing, People’s Republic of China
| | - Qiang Tong
- Department of Endocrinology, Chongqing Xinqiao Hospital, Chongqing, People’s Republic of China
| | - Min He
- Department of Endocrinology, The People’s Hospital of Shapingba District, Chongqing, People’s Republic of China
| | - Mei Yang
- Department of Endocrinology, The First People’s Hospital of Chongqing Liangjiang New Area, Chongqing, People’s Republic of China
| | - Xingrong Tan
- Department of Endocrinology, The 9th People’s Hospital of Chongqing, Chongqing, People’s Republic of China
| | - Lin Li
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, People’s Republic of China
| | - Zerong Liang
- Department of Endocrinology, Chongqing Red Cross Hospital, People’s Hospital of Jiangbei District, Chongqing, 400020, People’s Republic of China
| | - Yaqin Chen
- Department of Endocrinology, The People’s Hospital of Shizhu, Chongqing, People’s Republic of China
| | - Deqing Chen
- Department of Endocrinology, The People’s Hospital of Rongchang, Chongqing, People’s Republic of China
| | - David G Armstrong
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Wuquan Deng
- Department of Endocrinology, Chongqing University Central Hospital, Chongqing University, Chongqing, People’s Republic of China
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16
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Reliability of the Pedar in-shoe system for plantar pressure measurement in diabetic patients with and without neuropathy: a prospective study. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Luo B, Cai Y, Chen D, Wang C, Huang H, Chen L, Gao Y, Ran X. Effects of Special Therapeutic Footwear on the Prevention of Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Diabetes Res 2022; 2022:9742665. [PMID: 36204487 PMCID: PMC9530919 DOI: 10.1155/2022/9742665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 08/09/2022] [Accepted: 09/03/2022] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To reduce diabetic foot ulcer (DFU) occurrence or recurrence, diabetic therapeutic footwear is widely recommended in clinical practice for at-risk patients. However, the effectiveness of therapeutic footwear is controversial. Thus, we performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine whether special therapeutic footwear could reduce the incidence of DFU. METHOD We systematically searched multiple electronic databases (Medline, EMBASE, and EMB databases) to identify eligible studies published from inception to June 11, 2021. The database search, quality assessment, and data extraction were independently performed by two reviewers. Efficacy (i.e., incidence of DFU) was explored using the R'meta' package (version 4.15-1). To obtain more robust results, the random-effects model and the Hartung-Knapp-Sidik-Jonkman method were selected to assess pooled data. Metaregression analysis and sensitivity analysis were performed to explore heterogeneity, and publication bias was assessed by a visual inspection of funnel plots and the AS-Thompson test. RESULTS Eight RCTs with a total of 1,587 participants were identified from the search strategy. Compared with conventional footwear, special therapeutic footwear significantly reduced the incidence of DFU (RR 0.49; 95% CI, 0.28-0.84), with no evidence of publication bias (P = 0.69). Unexpectedly, the effectiveness of special therapeutic footwear had a reverse correlation with the intervention time (coefficient = 0.085, P < 0.05) in the metaregression analysis. CONCLUSION Special therapeutic footwear with offloading properties is effective in reducing the incidence of DFU. However, the effect may decrease gradually over time. Despite undefined reasons, the optimal utility time and renewal frequency of special therapeutic footwear should be considered.
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Affiliation(s)
- Bo Luo
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan, China
| | - Yuying Cai
- West China Medical School, Sichuan University, Chengdu, 610041 Sichuan, China
| | - Dawei Chen
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan, China
| | - Chun Wang
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan, China
| | - Hui Huang
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan, China
| | - Lihong Chen
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan, China
| | - Yun Gao
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan, China
| | - Xingwu Ran
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan, China
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18
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The Role of New Technological Opportunities and the Need to Evaluate the Activities Performed in the Prevention of Diabetic Foot with Exercise Therapy. MEDICINES 2021; 8:medicines8120076. [PMID: 34940288 PMCID: PMC8706849 DOI: 10.3390/medicines8120076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/22/2021] [Accepted: 11/28/2021] [Indexed: 01/22/2023]
Abstract
The diabetic foot (DF) is one of the most feared conditions among chronic complications of diabetes, which affects a growing number of patients. Although exercise therapy (ET) has always been considered a pillar in the treatment of patients at risk of DF it is not usually used. Several causes can contribute to hindering both the organization of ET protocols for Diabetes Units and the participation in ET programs for patients at different levels of risk of foot ulceration. The risk of favoring the occurrence of ulcers and the absence of clear evidence on the role played by ET in the prevention of ulcers could be considered among the most important causes leading to the low application of ET. The increased availability of new technologies and in particular of systems and devices equipped with sensors can enable the remote monitoring and management of physical activity performed by patients. Consequently, they can become an opportunity for introducing the systematic use of ET for the treatment of patients at risk. Considering the complexity of the clinical conditions that patients at risk or with diabetic foot ulcer can show, the evaluation of how patients perform the ET proposed can consequently be very important. All this can contribute to improving the treatment of patients and avoiding possible adverse effects. The aim of this brief review was to describe that the use of new technologies and the assessment of the execution of the ET proposed allows an important step forward in the management of patients at risk.
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19
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Lazzarini PA, Jarl G. Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:941. [PMID: 34577864 PMCID: PMC8471745 DOI: 10.3390/medicina57090941] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/03/2021] [Accepted: 09/04/2021] [Indexed: 12/21/2022]
Abstract
Diabetic foot ulcers (DFU) are a leading cause of the global disease burden. Most DFUs are caused, and prolonged, by high plantar tissue stress under the insensate foot of a person with peripheral neuropathy. Multiple different offloading treatments have been used to try to reduce high plantar tissue stress and heal DFUs, including bedrest, casting, offloading devices, footwear, and surgical procedures. The best offloading treatments are those that balance the benefits of maximizing reductions in high plantar tissue stress, whilst reducing the risks of poor satisfaction, high costs and potential adverse events outcomes. This review aimed to summarize the best available evidence on the effects of offloading treatments to heal people with DFUs, plus review their use in clinical practice, the common barriers and solutions to using these treatments, and discuss promising emerging solutions that may improve offloading treatments in future. Findings demonstrate that knee-high offloading devices, non-removable or removable knee-high devices worn for all weight-bearing activities, are the gold standard offloading treatments to heal most patients with DFU, as they are much more effective, and typically safer, quicker, and cheaper to use compared with other offloading treatments. The effectiveness of offloading treatments also seems to increase when increased offloading mechanical features are incorporated within treatments, including customized insoles, rocker-bottom soles, controlled ankle motion, and higher cast walls. However, in clinical practice these gold standard knee-high offloading devices have low rates of prescription by clinicians and low rates of acceptance or adherence by patients. The common barriers resulting in this low use seem to surround historical misperceptions that are mostly dispelled by contemporary evidence. Further, research is now urgently required to close the implementation gap between the high-quality of supporting evidence and the low use of knee-high devices in clinical practice to reduce the high global disease burden of DFU in future.
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Affiliation(s)
- Peter A. Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane 4059, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane 4032, Australia
| | - Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, SE-70182 Örebro, Sweden;
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, SE-70182 Örebro, Sweden
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20
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Qu W, Wang Z, Hunt C, Morrow AS, Urtecho M, Amin M, Shah S, Hasan B, Abd-Rabu R, Ashmore Z, Kubrova E, Prokop LJ, Murad MH. The Effectiveness and Safety of Platelet-Rich Plasma for Chronic Wounds: A Systematic Review and Meta-analysis. Mayo Clin Proc 2021; 96:2407-2417. [PMID: 34226023 DOI: 10.1016/j.mayocp.2021.01.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/16/2021] [Accepted: 01/26/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the effectiveness and adverse events of autologous platelet-rich plasma (PRP) in individuals with lower-extremity diabetic ulcers, lower-extremity venous ulcers, and pressure ulcers. PATIENTS AND METHODS We searched multiple databases from database inception to June 11, 2020, for randomized controlled trials and observational studies that compared PRP to any other wound care without PRP in adults with lower-extremity diabetic ulcers, lower-extremity venous ulcers, and pressure ulcers. RESULTS We included 20 randomized controlled trials and five observational studies. Compared with management without PRP, PRP therapy significantly increased complete wound closure in lower-extremity diabetic ulcers (relative risk, 1.20; 95% CI, 1.09 to 1.32, moderate strength of evidence [SOE]), shortened time to complete wound closure, and reduced wound area and depth (low SOE). No significant changes were found in terms of wound infection, amputation, wound recurrence, or hospitalization. In patients with lower-extremity venous ulcers or pressure ulcers, the SOE was insufficient to estimate an effect on critical outcomes, such as complete wound closure or time to complete wound closure. There was no statistically significant difference in adverse events. CONCLUSION Autologous PRP may increase complete wound closure, shorten healing time, and reduce wound size in individuals with lower-extremity diabetic ulcers. The evidence is insufficient to estimate an effect on wound healing in individuals with lower-extremity venous ulcers or pressure ulcers. TRIAL REGISTRATION PROSPERO Identifier: CRD42020172817.
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Affiliation(s)
- Wenchun Qu
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Department of Pain Medicine, Mayo Clinic, Jacksonville, FL
| | - Zhen Wang
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
| | - Christine Hunt
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Division of Pain Medicine, Department of Anaesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Allison S Morrow
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Meritxell Urtecho
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mustapha Amin
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Sahrish Shah
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Bashar Hasan
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rami Abd-Rabu
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Zack Ashmore
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Division of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | - Eva Kubrova
- Department of Pain Medicine, Mayo Clinic, Jacksonville, FL
| | - Larry J Prokop
- Department of Library-Public Services, Mayo Clinic, Rochester, MN
| | - Mohammad Hassan Murad
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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21
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Saliba Thorne C, Gatt A, DeRaffaele C, Bazena A, Formosa C. Digital foot health technology and diabetic foot monitoring: A systematic review. Diabetes Res Clin Pract 2021; 175:108783. [PMID: 33775686 DOI: 10.1016/j.diabres.2021.108783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/17/2020] [Accepted: 03/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In diabetic foot ulceration, a correlation between pressure and skin temperature is suspected. The aim of this systematic review is to provide a more rigorous analysis of existing literature related to the various technologies used to read and measure both in-shoe plantar pressures, and in-shoe skin temperatures simultaneously. METHODS A systematic review of the literature related to the topic was searched in database sources such as Medline OVID, Cochrane Library, PubMed, CONAHL, PROSPERO, and Elsevier. Outcome measures of interest included validity, reliability and responsiveness of in-shoe temperature and/or pressure mapping device used, and characteristics and quantity of sensors used, anatomical landmarks and statistical analysis used to interpret the data. Quality of evidence and risk of bias was evaluated using the QUADAS-2. RESULTS Nineteen studies were identified and included in this review. The majority of studies used a small sample size (mean n = 17) and recruited healthy participants. All studies have shown excellent validity but only a few tested for the reliability of the device. None of the studies tested for responsiveness of the device. Quality assessment results scored high risk in view of 'patient selection', 'use of reference standard' and 'applicability', and low risk in view of 'use if index test' and 'flow and timing'. CONCLUSIONS The data outlined in this review confirms that further improvement, reliability testing and clinical validation of the developed systems is required despite the results of excellent performance in detecting changes of in-shoe skin temperature and pressure.
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Affiliation(s)
| | - Alfred Gatt
- Faculty of Health Sciences, University of Malta, Malta
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22
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The Association between Cognitive Impairment and Diabetic Foot Care: Role of Neuropathy and Glycated Hemoglobin. PATHOPHYSIOLOGY 2020; 27:14-27. [PMID: 35366252 PMCID: PMC8830443 DOI: 10.3390/pathophysiology27010003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/23/2020] [Accepted: 11/23/2020] [Indexed: 12/29/2022] Open
Abstract
Diabetes mellitus is associated with impairment in cognitive functions which can complicate adherence to self-care behaviors. We evaluated the incidence of cognitive impairment in patients with diabetes mellitus to determine the strength of the association between diabetic foot (a complication that occurs in about 10% of diabetic patients), adherence to the clinician’s recommendations, glycemic control, and cognitive function. A prospective study was carried out in a probabilistic sample of older patients with diabetic foot living in three nursing homes. Cognitive functions were evaluated by the MMSE (Mini-Mental State Examination), the Trail Making test (TMT), and the Michigan neuropathy screening instrument (MNSI). There were no significant associations between cognitive function and neuropathy or foot alterations, although glycated hemoglobin (HB1Ac > 7%) significantly (p < 0.05) associated with MMSE and adherence to treatment in the 1 month follow-up visit. Receiver operating characteristic curve analysis showed that both HB1Ac and the MNSI score significantly (p < 0.05) discriminate subsequent adherence to treatment for foot complication, with a sensitivity of 80.0–73.3% and specificity 70.6–64.7%, respectively. Proper control of foot complications in diabetic patients involves appropriate glycemic control and less severe neuropathy, and seems to be unrelated to cognitive dysfunction, and warrants further studies in order to tailor appropriate treatments to central and peripheral nervous system disorders. Poor glycemic control (Hb1Ac level > 7%) and a neuropathy score of 5.5 in the MNSI are the best-cut off points to discriminate poor adherence to the clinician’s recommendations for self-care behaviors in people with diabetic foot complication. In this study, we observed that foot disorders were associated with impaired global cognitive function in elderly patients (aged ≥ 65). Podiatrists and physicians should consider cognitive dysfunction as an important chronic complication in the management of diabetic foot.
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Alahakoon C, Fernando M, Galappaththy C, Matthews EO, Lazzarini P, Moxon JV, Golledge J. Meta-analyses of randomized controlled trials reporting the effect of home foot temperature monitoring, patient education or offloading footwear on the incidence of diabetes-related foot ulcers. Diabet Med 2020; 37:1266-1279. [PMID: 32426872 DOI: 10.1111/dme.14323] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2020] [Indexed: 01/27/2023]
Abstract
AIM The aim of this study was to perform an up-to-date systematic review and meta-analysis of randomized controlled trials (RCTs) examining the efficacy of home foot temperature monitoring, patient education and offloading footwear in reducing the incidence of diabetes-related foot ulcers. METHODS A literature search was performed using MEDLINE, PubMed, CINAHL, Scopus and Cochrane databases to identify relevant original studies. Meta-analyses were performed using intention-to-treat principals for worst (main analysis) and best (sub-analysis) case scenarios. Leave-one-out sensitivity analyses were used to assess the consistency of findings. RESULTS Of 7575 unique records, 17 RCTs involving 2729 participants were included. Four tested home foot temperature monitoring (n = 468), six examined patient education (n = 823) and seven assessed offloading footwear (n = 1438). Participants' who performed home foot temperature monitoring [odds ratio (OR) 0.51, 95% confidence interval (CI) 0.31 to 0.84; n = 468] and those provided offloading footwear (OR 0.48, 95% CI 0.29 to 0.80; n = 1438) were less likely to develop a diabetes-related foot ulcer. Patient education programmes did not significantly reduce diabetes-related foot ulcer incidence (OR 0.59, 95% CI 0.29 to 1.20; n = 823). Sensitivity analyses suggested that offloading footwear findings were consistent, but home foot temperature findings were dependent on the individual inclusion of one trial. All RCTs had either high or unclear risk of bias. CONCLUSION This meta-analysis suggests that offloading footwear is effective in reducing the incidence of diabetes-related foot ulcers. Home foot temperature monitoring also appears beneficial but larger trials are needed (PROSPERO registration no.: CRD42019135226).
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Affiliation(s)
- C Alahakoon
- Ulcer and Wound Healing Consortium (UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Townsville, Australia
- Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - M Fernando
- Ulcer and Wound Healing Consortium (UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Townsville, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia
| | - C Galappaththy
- Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, Australia
| | - E O Matthews
- Ulcer and Wound Healing Consortium (UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Townsville, Australia
| | - P Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
- Allied Health Research Collaborative, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - J V Moxon
- Ulcer and Wound Healing Consortium (UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Townsville, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia
| | - J Golledge
- Ulcer and Wound Healing Consortium (UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Townsville, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia
- Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, Australia
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Ahmed S, Barwick A, Butterworth P, Nancarrow S. Footwear and insole design features that reduce neuropathic plantar forefoot ulcer risk in people with diabetes: a systematic literature review. J Foot Ankle Res 2020; 13:30. [PMID: 32498719 PMCID: PMC7271493 DOI: 10.1186/s13047-020-00400-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/22/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In people with diabetes, offloading high-risk foot regions by optimising footwear, or insoles, may prevent ulceration. This systematic review aimed to summarise and evaluate the evidence for footwear and insole features that reduce pathological plantar pressures and the occurrence of diabetic neuropathy ulceration at the plantar forefoot in people with diabetic neuropathy. METHODS Six electronic databases (Medline, Cinahl, Amed, Proquest, Scopus, Academic Search Premier) were searched in July 2019. The search period was from 1987 to July 2019. Articles, in English, using footwear or insoles as interventions in patients with diabetic neuropathy were reviewed. Any study design was eligible for inclusion except systematic literature reviews and case reports. Search terms were diabetic foot, physiopathology, foot deformities, neuropath*, footwear, orthoses, shoe, footwear prescription, insole, sock*, ulcer prevention, offloading, foot ulcer, plantar pressure. RESULTS Twenty-five studies were reviewed. The included articles used repeated measure (n = 12), case-control (n = 3), prospective cohort (n = 2), randomised crossover (n = 1), and randomised controlled trial (RCT) (n = 7) designs. This involved a total of 2063 participants. Eleven studies investigated footwear, and 14 studies investigated insoles as an intervention. Six studies investigated ulcer recurrence; no study investigated the first occurrence of ulceration. The most commonly examined outcome measures were peak plantar pressure, pressure-time integral and total contact area. Methodological quality varied. Strong evidence existed for rocker soles to reduce peak plantar pressure. Moderate evidence existed for custom insoles to offload forefoot plantar pressure. There was weak evidence that insole contact area influenced plantar pressure. CONCLUSION Rocker soles, custom-made insoles with metatarsal additions and a high degree of contact between the insole and foot reduce plantar pressures in a manner that may reduce ulcer occurrence. Most studies rely on reduction in plantar pressure measures as an outcome, rather than the occurrence of ulceration. There is limited evidence to inform footwear and insole interventions and prescription in this population. Further high-quality studies in this field are required.
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Affiliation(s)
- Sayed Ahmed
- School of Health and Human Sciences, Southern Cross University, Billinga, Queensland 4225 Australia
| | - Alex Barwick
- School of Health and Human Sciences, Southern Cross University, Billinga, Queensland 4225 Australia
| | - Paul Butterworth
- School of Health and Human Sciences, Southern Cross University, Billinga, Queensland 4225 Australia
| | - Susan Nancarrow
- School of Health and Human Sciences, Southern Cross University, Billinga, Queensland 4225 Australia
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25
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Emerging technologies for the prevention and management of diabetic foot ulcers. J Tissue Viability 2020; 29:61-68. [DOI: 10.1016/j.jtv.2020.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/27/2019] [Accepted: 03/14/2020] [Indexed: 12/14/2022]
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Chatwin KE, Abbott CA, Boulton AJ, Bowling FL, Reeves ND. The role of foot pressure measurement in the prediction and prevention of diabetic foot ulceration-A comprehensive review. Diabetes Metab Res Rev 2020; 36:e3258. [PMID: 31825163 PMCID: PMC7317473 DOI: 10.1002/dmrr.3258] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 12/19/2022]
Abstract
The predominant risk factor of diabetic foot ulcers (DFU), peripheral neuropathy, results in loss of protective sensation and is associated with abnormally high plantar pressures. DFU prevention strategies strive to reduce these high plantar pressures. Nevertheless, several constraints should be acknowledged regarding the research supporting the link between plantar pressure and DFUs, which may explain the low prediction ability reported in prospective studies. The majority of studies assess vertical, rather than shear, barefoot plantar pressure in laboratory-based environments, rather than during daily activity. Few studies investigated previous DFU location-specific pressure. Previous studies focus predominantly on walking, although studies monitoring activity suggest that more time is spent on other weight-bearing activities, where a lower "peak" plantar pressure might be applied over a longer duration. Although further research is needed, this may indicate that an expression of cumulative pressure applied over time could be a more relevant parameter than peak pressure. Studies indicated that providing pressure feedback might reduce plantar pressures, with an emerging potential use of smart technology, however, further research is required. Further pressure analyses, across all weight-bearing activities, referring to location-specific pressures are required to improve our understanding of pressures resulting in DFUs and improve effectiveness of interventions.
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Affiliation(s)
- Katie E. Chatwin
- Musculoskeletal Science & Sports Medicine Research Centre, Department of Life Sciences, Faculty of Science & EngineeringManchester Metropolitan UniversityManchesterUK
| | - Caroline A. Abbott
- Musculoskeletal Science & Sports Medicine Research Centre, Department of Life Sciences, Faculty of Science & EngineeringManchester Metropolitan UniversityManchesterUK
| | - Andrew J.M. Boulton
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Diabetes Research InstituteUniversity of MiamiMiamiFlorida
| | - Frank L. Bowling
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Neil D. Reeves
- Musculoskeletal Science & Sports Medicine Research Centre, Department of Life Sciences, Faculty of Science & EngineeringManchester Metropolitan UniversityManchesterUK
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Qi L, Ahmadi AR, Huang J, Chen M, Pan B, Kuwabara H, Iwasaki K, Wang W, Wesson R, Cameron AM, Cui S, Burdick J, Sun Z. Major Improvement in Wound Healing Through Pharmacologic Mobilization of Stem Cells in Severely Diabetic Rats. Diabetes 2020; 69:699-712. [PMID: 31974141 DOI: 10.2337/db19-0907] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/11/2020] [Indexed: 11/13/2022]
Abstract
Current therapeutic strategies for diabetic foot ulcer (DFU) have focused on developing topical healing agents, but few agents have controlled prospective data to support their effectiveness in promoting wound healing. We tested a stem cell mobilizing therapy for DFU using a combination of AMD3100 and low-dose FK506 (tacrolimus) (AF) in streptozocin-induced type 1 diabetic (T1DM) rats and type 2 diabetic Goto-Kakizaki (GK) rats that had developed peripheral artery disease and neuropathy. Here, we show that the time for healing back wounds in T1DM rats was reduced from 27 to 19 days, and the foot wound healing time was reduced from 25 to 20 days by treatment with AF (subcutaneously, every other day). Similarly, in GK rats treated with AF, the healing time on back wounds was reduced from 26 to 21 days. Further, this shortened healing time was accompanied by reduced scar and by regeneration of hair follicles. We found that AF therapy mobilized and recruited bone marrow-derived CD133+ and CD34+ endothelial progenitor cells and Ym1/2+ M2 macrophages into the wound sites, associated with enhanced capillary and hair follicle neogenesis. Moreover, AF therapy improved microcirculation in diabetic and neuropathic feet in GK rats. This study provides a novel systemic therapy for healing DFU.
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Affiliation(s)
- Le Qi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Ali Reza Ahmadi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jinny Huang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Melissa Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Baohan Pan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hiroshi Kuwabara
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kenichi Iwasaki
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wei Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Russell Wesson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shusen Cui
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - James Burdick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Zhaoli Sun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Risk factors for plantar foot ulcer recurrence in patients with diabetes - A prospective pilot study. J Tissue Viability 2020; 29:135-137. [PMID: 32044183 DOI: 10.1016/j.jtv.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/30/2019] [Accepted: 02/01/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Diabetic foot ulcer (DFU) is a complication of diabetes mellitus (DM) with established recurrence risk factors evaluating patients from United States or Europe. There are scarce studies in developing countries about these risks. The aim of this study was to evaluate risk factors associated with DFU recurrence in a Brazilian prospective cohort. MATERIALS AND METHODS A prospective cohort of patients with healed DFU followed from January 2014 to June 2017 in Curitiba, Brazil. Periodic home visits from a specialist nurse in DFU were performed during the period of the study to evaluate recurrence of ulcer. The presence of risk factors in the group of patients that developed an ulcer in the follow-up period was compared with the presence of these factors in the group of patients without recurrence. At enrollment, 35 subjects presented a previous ulcer distal with complete healing to follow-up. RESULTS From 35 patients, 15 were male (43%) and the mean age was of 65.8 ± 10.9 years (48-85 year). Most patients were married with a low income (<US$ 250/month). The mean BMI was 26.5 ± 5.6 kg/cm2. Seventy-four percent (26/35) had another comorbidity. The mean duration of DM until ulcer was 14.6 ± 5.2 years. The global mortality during the study (3 years) was 14%. The DFU recurred in 23 patients (65.7%). Both groups had similar findings, except by lower income (<US$ 250/month) in the group of recurrent DFU. CONCLUSION Recurrence of DFU is frequent and associated with low familiar income in a pilot Brazilian study.
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Mehlhorn AT, Harrasser N, Walther M. [Treatment of plantar, neuropathic and metatarsal ulcers by minimally invasive metatarsal osteotomy]. DER ORTHOPADE 2019; 49:625-631. [PMID: 31863150 DOI: 10.1007/s00132-019-03848-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The chronic-mechanical plantar ulcer in diabetic-neuropathic foot syndrome is the starting point for severe infections of the foot and amputations. Frequent predilection sites are the metatarsal heads (MTH); in the context of neuropathy increased plantar peak pressure occurs and leads to an ulcer. GOAL In this paper, we will examine whether minimally invasive pressure-reducing osteotomies, such as distal, minimally invasive metatarsal osteotomy (DMMO), can lead to the healing of metatarsal ulcers. Furthermore, the frequency of postoperative complications will be analyzed. METHOD In a prospective study, n = 26 consecutive patients with plantar grade IA, IIA, and IIIA ulcers according to Wagner/Armstrong were included in the study under MTH 2, 3, 4 and 5 and with an unsuccessful conservative therapy >6 months. All patients received a DMMO of MT 2, 3, and 4, unless the ulcer was under MTH 5, then isolated DMMO MT 5 was performed. Clinical radiological check-ups took place over a follow-up interval of 26 ± 18 months (8-43 months). RESULTS In all patients, the plantar ulcera healed after 5 ± 1 week, the recurrence rate was 8% and 3 patients had a transfer ulcer. Complications such as infection, pseudarthrosis or neuroosteoarthropathy did not occur. CONCLUSION DMMO is an effective method for the treatment of recalcitrant ulcers under the metatarsal heads. The rate of a long-term cure is high; the complication rate is low; in ulcers under MTH 5, the DMMO should possibly be extended to the other metatarsal heads to reduce the risk of a transfer ulcer.
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Affiliation(s)
- Alexander T Mehlhorn
- Zentrum für Fuß- und Sprunggelenkschirurgie, Schönklinik München-Harlaching, Harlachingerstraße 51, 81547, München, Deutschland.
- Klinik für Orthopädie und Unfallchirurgie, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland.
| | - Norbert Harrasser
- Zentrum für Fuß- und Sprunggelenkschirurgie, Schönklinik München-Harlaching, Harlachingerstraße 51, 81547, München, Deutschland
| | - Markus Walther
- Zentrum für Fuß- und Sprunggelenkschirurgie, Schönklinik München-Harlaching, Harlachingerstraße 51, 81547, München, Deutschland
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Akturk A, van Netten JJ, Scheer R, Vermeer M, van Baal JG. Ulcer-free survival days and ulcer healing in patients with diabetic foot ulcers: A prospective cohort study. Int Wound J 2019; 16:1365-1372. [PMID: 31429183 PMCID: PMC7948914 DOI: 10.1111/iwj.13199] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/02/2019] [Accepted: 08/04/2019] [Indexed: 01/22/2023] Open
Abstract
Healing rates may not give a complete indication of the effectiveness and management of diabetic foot ulcers because of high recurrence rates. The most important outcome for patients is remaining ulcer-free; however, this has hardly been investigated. The aim of our study was to prospectively investigate ulcer-free survival days and ulcer healing in patients with diabetic foot ulcers. This was a prospective cohort study of all referrals to our diabetic foot expertise centre from December 2014 to April 2017. Outcomes were determined after a minimum follow-up period of 12 months. Primary outcomes were ulcer-free survival days and 12-month healing percentages. Predictors for ulcer-free survival days and healing were investigated in multivariate analyses. A total of 158 patients were included. Median ulcer-free survival days in the healed group were 233 days (interquartile range [IQR] 121-312) and 131 days (IQR 0-298) in the overall population. The healing rate at 12-month follow up was 67% (106/158), and the recurrence rate was 31% (33/106). Independent predictors of ulcer-free survival days were duration of diabetes, peripheral artery disease (PAD), cardiovascular disease, end-stage renal disease (ESRD), and infection. Ulcer-free survival days are related to PAD and cardiovascular disease, and ulcer-free survival days should be the main outcome when comparing the effectiveness of management and prevention of the diabetic foot ulcers.
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Affiliation(s)
- Afram Akturk
- Department of SurgeryZiekenhuisgroep Twente (ZGT)Almelo and HengeloThe Netherlands
| | - Jaap J. van Netten
- Department of SurgeryZiekenhuisgroep Twente (ZGT)Almelo and HengeloThe Netherlands
- Amsterdam UMC, University of AmsterdamDepartment of Rehabilitation, Amsterdam Movement SciencesAmsterdamThe Netherlands
- School of Clinical SciencesQueensland University of TechnologyBrisbaneAustralia
| | - Rene Scheer
- Department of SurgeryZiekenhuisgroep Twente (ZGT)Almelo and HengeloThe Netherlands
| | - Marloes Vermeer
- ZGT AcademyZiekenhuisgroep Twente (ZGT)Almelo and HengeloThe Netherlands
| | - Jeff G. van Baal
- Department of SurgeryZiekenhuisgroep Twente (ZGT)Almelo and HengeloThe Netherlands
- University of CardiffCardiffUK
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Lazzarini PA, Crews RT, van Netten JJ, Bus SA, Fernando ME, Chadwick PJ, Najafi B. Measuring Plantar Tissue Stress in People With Diabetic Peripheral Neuropathy: A Critical Concept in Diabetic Foot Management. J Diabetes Sci Technol 2019; 13:869-880. [PMID: 31030546 PMCID: PMC6955461 DOI: 10.1177/1932296819849092] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Excessive stress on plantar tissue over time is one of the leading causes of diabetic foot ulcers among people with diabetic peripheral neuropathy. Plantar tissue stress (PTS) is a concept that attempts to integrate several well-known mechanical factors into one measure, including plantar pressure, shear stress, daily weight-bearing activity, and time spent in prescribed offloading interventions (adherence). Despite international diabetic foot guidelines recommending the measure of each of these individual mechanical factors in people with neuropathy, only recently has technology enabled their combined measurement to determine PTS. In this article we review the concept of PTS, the mechanical factors involved, and the findings of pivotal articles reporting measures of PTS in people with neuropathy. We also discuss key existing gaps in this field, including the lack of standards to measure and report PTS, a lack of practical solutions to measure shear stress, and the lack of PTS thresholds that may indicate benefit or detriment to people with neuropathy. To address some of these gaps, we propose recommended clinical and research standards for measuring and reporting PTS in people with neuropathy. Last, we forecast future clinical, research, and technological advancements that may use PTS to highlight the importance of this critical concept in the prevention and management of diabetic foot ulcers.
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Affiliation(s)
- Peter A. Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia
- Peter A. Lazzarini, PhD, School of Public Health and Social Work, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Brisbane, Queensland 4059, Australia.
| | - Ryan T. Crews
- Center for Lower Extremity Ambulatory Research (CLEAR), Dr William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Jaap J. van Netten
- Amsterdam UMC, Department of Rehabilitation, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Ziekenhuisgroep Twente, Department of Surgery, Almelo and Hengelo, the Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Sicco A. Bus
- Amsterdam UMC, Department of Rehabilitation, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Malindu E. Fernando
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | | | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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Fu XL, Ding H, Miao WW, Mao CX, Zhan MQ, Chen HL. Global recurrence rates in diabetic foot ulcers: A systematic review and meta-analysis. Diabetes Metab Res Rev 2019; 35:e3160. [PMID: 30916434 DOI: 10.1002/dmrr.3160] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/22/2019] [Accepted: 03/17/2019] [Indexed: 12/23/2022]
Abstract
Recurrence rates of diabetic foot ulcers vary widely in the published literature. The aim of this systematic review is to estimate recurrence rates of diabetic foot ulcers. We did a PubMed search and performed a review of reference lists for studies reporting recurrence of diabetic foot ulcers. The weighted relative risk (RR) and corresponding 95% confidence interval (CI) for recurrence was estimated. Forty-nine studies reporting recurrence of diabetic foot ulcers were included. A pooled estimate for recurrence rate was 22.1% per person-year (py) (95% CI, 19.0-25.2%). Recurrence rate was 24.9% per py in Europe (95% CI, 20.0%-29.7%), 17.8% per py in North America (95% CI, 12.7%-22.9%), 16.9% per py in Africa (95% CI, 4.7%-29.0%), and 17.0% per py in Asia (95% CI, 11.1%-23.0%). Turkey had the highest recurrence rate of 44.4% per py (95% CI, 24.9%-63.9%), and Bangladesh had the lowest of 4.3% per py (95% CI, 2.3%-6.3%). Recurrence rates of diabetic foot ulcers before 2002, between 2002 and 2008, and after 2008 were 22.2% per py (95% CI, 17.6%-26.8%), 21.9% per py (95% CI, 17.0%-26.8%), and 21.8% per py (95% CI, 16.3%-27.2%), respectively. Recurrence rates of diabetic foot ulcers are high. Recurrence rates vary widely in different regions and have decreased recently. More attention towards recurrence of diabetic foot ulcers is urgently required.
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Affiliation(s)
- Xue-Lei Fu
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Hui Ding
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Wei-Wei Miao
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Chun-Xing Mao
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Min-Qi Zhan
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Hong-Lin Chen
- School of Public Health, Nantong University, Nantong, China
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Searle MOsteo A, Spink MJ, Chuter VH. Validation of a weight bearing ankle equinus value in older adults with diabetes. J Foot Ankle Res 2018; 11:62. [PMID: 30479667 PMCID: PMC6249959 DOI: 10.1186/s13047-018-0306-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 11/05/2018] [Indexed: 12/13/2022] Open
Abstract
Background Accurate measurement of ankle joint dorsiflexion is clinically important as a restriction has been linked to many foot and ankle pathologies, as well as increased ulcer risk and delayed ulcer healing in people with diabetes. Use of the reliable weight bearing (WB) Lunge test is limited as normal and restricted ranges for WB ankle joint dorsiflexion are not identified. Additionally the extent of WB dorsiflexion restriction that results in clinically adverse outcomes is unclear. Therefore the aim of this investigation is to validate a proposed weight bearing equinus value (dorsiflexion < 30°) in unimpaired cohorts, and secondly to investigate any clinical effects this degree of ankle dorsiflexion restriction has on forefoot plantar pressure variables in older adults with diabetes. Methods Ankle dorsiflexion was measured using a Lunge test with the knee extended in young adults without diabetes (YA) and older adults with diabetes (DA). In-shoe and barefoot plantar pressure was recorded for the DA group. Spearman’s correlation was calculated to determine any association between the presence of ankle equinus and plantar pressure variables in the DA group. DA group differences in people with and without an equinus were examined. Results A weight bearing equinus of < 30°, assessed in a lunge using an inclinometer placed on the anterior tibia, falls within the restricted range in young unimpaired cohorts. In the DA group this degree of ankle restriction had a fair and significant association with elevated barefoot forefoot peak pressure (r = 0.274, p = 0.005) and pressure-time integrals (r = 0.321, p = .001). The DA equinus group had significantly higher barefoot peak pressure (mean kPa (SD): 787.1 (246.7) vs 652.0 (304.5), p = 0.025) and pressure-time integrals (mean kPa (SD): 97.8 (41.6) vs 80.4 (30.5), p = 0.017) than the DA non equinus group. Conclusions We support a preliminary weight bearing ankle equinus value of < 30°. This value represents a restricted range in young adults and is correlated with increased forefoot plantar pressure variables in older adults with diabetes. Mean population weight bearing ankle dorsiflexion data presented here for older adults with diabetes, will allow use of the more functional Lunge test with knee extended in research and clinical practice.
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Affiliation(s)
- A Searle MOsteo
- 1School of Health Sciences, Faculty of Health, University of Newcastle, PO Box 127, Ourimbah, NSW 2258 Australia
| | - M J Spink
- 1School of Health Sciences, Faculty of Health, University of Newcastle, PO Box 127, Ourimbah, NSW 2258 Australia
| | - V H Chuter
- 1School of Health Sciences, Faculty of Health, University of Newcastle, PO Box 127, Ourimbah, NSW 2258 Australia.,2Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, PO Box 127, Ourimbah, NSW 2258 Australia
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Collings R, Freeman J, Latour JM, Glasser S, Paton J. Footwear and insole design features to prevent foot ulceration in people with diabetes: a systematic review protocol. ACTA ACUST UNITED AC 2017; 15:1824-1834. [PMID: 28708747 DOI: 10.11124/jbisrir-2016-003291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The aim of this systematic review is to identify the key design features of footwear and insoles that are used to offload the plantar surface of the foot to prevent foot ulceration in adults with diabetes.More specifically, the objectives are to identify the key design features of footwear and insoles to offload the plantar surface of the foot with regard to.
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Affiliation(s)
- Richard Collings
- 1School of Health Professions, Faculty of Health and Human Sciences, Plymouth University, Plymouth, United Kingdom 2Department of Podiatry, Torbay and Southern Devon NHS Foundation Trust, Torquay, United Kingdom 3School of Nursing and Midwifery, Faculty of Health and Human Sciences, Plymouth University, Plymouth, United Kingdom 4The University of Plymouth Centre for Innovations in Health and Social Care: a Joanna Briggs Institute Centre of Excellence
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Affiliation(s)
- David G Armstrong
- From the Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson (D.G.A.); Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (D.G.A., A.J.M.B.); and the Department of Rehabilitation Medicine, Academic Medical Center, University of Amsterdam, and Amsterdam Movement Sciences - both in Amsterdam (S.A.B.)
| | - Andrew J M Boulton
- From the Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson (D.G.A.); Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (D.G.A., A.J.M.B.); and the Department of Rehabilitation Medicine, Academic Medical Center, University of Amsterdam, and Amsterdam Movement Sciences - both in Amsterdam (S.A.B.)
| | - Sicco A Bus
- From the Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson (D.G.A.); Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (D.G.A., A.J.M.B.); and the Department of Rehabilitation Medicine, Academic Medical Center, University of Amsterdam, and Amsterdam Movement Sciences - both in Amsterdam (S.A.B.)
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Diabetic foot ulcer off-loading: The gap between evidence and practice. Data from the US Wound Registry. Adv Skin Wound Care 2017; 27:310-6. [PMID: 24932951 DOI: 10.1097/01.asw.0000450831.65667.89] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the practice of off-loading diabetic foot ulcers (DFUs) using real-world data from a large wound registry to better identify and understand the gap between evidence and practice. DESIGN Retrospective, deidentified data were extracted from the US Wound Registry based on patient/wound characteristics, procedures performed, and at which clinic the DFU was treated. SETTING 96 clinics (23 from the United States and Puerto Rico) PATIENTS : 11,784 patients; 25,114 DFUs MAIN OUTCOME MEASURES : Healed/not healed, amputated, percent off-loading, percent use of total contact casting (TCC), infection rate MAIN RESULTS : Off-loading was documented in only 2.2% of 221,192 visits from January 2, 2007, to January 6, 2013. The most common off-loading option was the postoperative shoe (36.8%) and TCC (16.0%). There were significantly more amputations within 1 year for non-TCC-treated DFUs compared with TCC-treated DFUs (5.2% vs 2.2%; P = .001). The proportion of healed wounds was slightly higher for TCC-treated DFUs versus non-TCC-treated DFUs (39.4% vs 37.2%). Infection rates were significantly higher for non-TCC-treated DFUs compared with TCC-treated DFUs (2.6 vs 1.6; P = 2.1 × 10). Only 59 clinics used TCC (61%); 57% of those clinics used traditional TCC, followed by TCC-EZ (36%). Among clinics using any type of TCC, 96.3% of the DFUs that did not receive TCC were "TCC-eligible" ulcers. Among clinics using "traditional" TCC systems, 1.4% of DFUs were treated with TCC, whereas clinics using TCC-EZ provided TCC to 6.2% of DFUs. CONCLUSION Total contact casting is vastly underutilized in DFU wound care settings, suggesting that there is a gap in practice for adequate off-loading. New, easier-to-apply TCC kits, such as the TCC-EZ, may increase the frequency with which this ideal form of adequate off-loading is utilized.
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Off-loading strategies in diabetic foot syndrome–evaluation of different devices. INTERNATIONAL ORTHOPAEDICS 2016; 41:239-246. [DOI: 10.1007/s00264-016-3358-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 11/21/2016] [Indexed: 10/20/2022]
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Caravaggi P, Leardini A, Giacomozzi C. Multiple linear regression approach for the analysis of the relationships between joints mobility and regional pressure-based parameters in the normal-arched foot. J Biomech 2016; 49:3485-3491. [PMID: 27660173 DOI: 10.1016/j.jbiomech.2016.09.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/15/2022]
Abstract
Plantar load can be considered as a measure of the foot ability to transmit forces at the foot/ground, or foot/footwear interface during ambulatory activities via the lower limb kinematic chain. While morphological and functional measures have been shown to be correlated with plantar load, no exhaustive data are currently available on the possible relationships between range of motion of foot joints and plantar load regional parameters. Joints' kinematics from a validated multi-segmental foot model were recorded together with plantar pressure parameters in 21 normal-arched healthy subjects during three barefoot walking trials. Plantar pressure maps were divided into six anatomically-based regions of interest associated to corresponding foot segments. A stepwise multiple regression analysis was performed to determine the relationships between pressure-based parameters, joints range of motion and normalized walking speed (speed/subject height). Sagittal- and frontal-plane joint motion were those most correlated to plantar load. Foot joints' range of motion and normalized walking speed explained between 6% and 43% of the model variance (adjusted R2) for pressure-based parameters. In general, those joints' presenting lower mobility during stance were associated to lower vertical force at forefoot and to larger mean and peak pressure at hindfoot and forefoot. Normalized walking speed was always positively correlated to mean and peak pressure at hindfoot and forefoot. While a large variance in plantar pressure data is still not accounted for by the present models, this study provides statistical corroboration of the close relationship between joint mobility and plantar pressure during stance in the normal healthy foot.
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Affiliation(s)
- Paolo Caravaggi
- Movement Analysis Laboratory and Functional Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - Alberto Leardini
- Movement Analysis Laboratory and Functional Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Claudia Giacomozzi
- Department of Technology and Health, Istituto Superiore di Sanità (Italian National Institute of Health), Rome, Italy
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Oliveira AFD, Marchi ACBD, Leguisamo CP. Diabetic footwear: is it an assistive technology capable of reducing peak plantar pressures in elderly patients with neuropathy? FISIOTERAPIA EM MOVIMENTO 2016. [DOI: 10.1590/1980-5918.029.003.ao04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Abstract Introduction: Diabetes Mellitus is a chronic disease with high prevalence in the population in particular among the elderly. The longer time of diabetes, increased the chances of developing complications such as peripheral neuropathy, which is an important factor in the genesis of plantar lesions by changing the distribution and formation of plantar pressure peaks. Objective: Evaluate the influence of an Assistive Technology, therapeutic footwear for diabetics, in the peaks of plantar pressure of elderly. Methods: This was an experimental study of transversal type, composed by 10 elderly, diabetic, with peripheral neuropathy, using as an instrument to measure a baropodometry platform. Were measured peaks of plantar pressure, static and dynamic in three situations: barefoot, the participants' own standard footwear and with therapeutic footwear for diabetics. Data analysis by normal distribution as a single paired sample, applying the ANOVA test. Results: The use of therapeutic footwear for diabetics promoted a reduction in media of peak plantar pressure in the order of 22% in static analysis, and 31% in dynamic analysis. Conclusion: The therapeutic footwear for diabetics was able to produce significant reductions in peak plantar pressure, being more efficient than a common footwear. This effect may contribute to the prevention of injuries associated with the diabetic foot.
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Niemann U, Spiliopoulou M, Szczepanski T, Samland F, Grützner J, Senk D, Ming A, Kellersmann J, Malanowski J, Klose S, Mertens PR. Comparative Clustering of Plantar Pressure Distributions in Diabetics with Polyneuropathy May Be Applied to Reveal Inappropriate Biomechanical Stress. PLoS One 2016; 11:e0161326. [PMID: 27529421 PMCID: PMC4987010 DOI: 10.1371/journal.pone.0161326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 08/03/2016] [Indexed: 12/30/2022] Open
Abstract
In diabetic patients, excessive peak plantar pressure has been identified as major risk factor for ulceration. Analyzing plantar pressure distributions potentially improves the identification of patients with a high risk for foot ulceration development. The goal of this study was to classify regional plantar pressure distributions. By means of a sensor-equipped insole, pressure recordings of healthy controls (n = 18) and diabetics with severe polyneuropathy (n = 25) were captured across eight foot regions. The study involved a controlled experimental protocol with multiple sessions, where a session contained several cycles of pressure exposure. Clustering was used to identify subgroups of study participants that are characterized by similar pressure distributions. For both analyzed groups, the number of clusters to best describe the pressure profiles was four. When both groups were combined, analysis again led to four distinct clusters. While three clusters did not separate between healthy and diabetic volunteers the fourth cluster was only represented by diabetics. Here the pressure distribution pattern is characterized by a focal point of pressure application on the forefoot and low pressure on the lateral region. Our data suggest that pressure clustering is a feasible means to identify inappropriate biomechanical plantar stress.
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Affiliation(s)
- Uli Niemann
- Faculty of Computer Science, Otto-von-Guericke University, Magdeburg, Germany
- ifak system GmbH, Magdeburg, Germany
- * E-mail: (UN); (PRM)
| | - Myra Spiliopoulou
- Faculty of Computer Science, Otto-von-Guericke University, Magdeburg, Germany
| | | | | | | | - Dominik Senk
- Clinic for Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Antao Ming
- Clinic for Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Juliane Kellersmann
- Clinic for Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Jan Malanowski
- Clinic for Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Silke Klose
- Clinic for Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Peter R. Mertens
- Clinic for Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
- * E-mail: (UN); (PRM)
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Scott JE, Hendry GJ, Locke J. Effectiveness of percutaneous flexor tenotomies for the management and prevention of recurrence of diabetic toe ulcers: a systematic review. J Foot Ankle Res 2016; 9:25. [PMID: 27478505 PMCID: PMC4966795 DOI: 10.1186/s13047-016-0159-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/26/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diabetic toe ulcers are a potentially devastating complication of diabetes. In recent years, the percutaneous flexor tenotomy procedure for the correction of flexible claw and hammer-toe contraction deformities has been proposed as a safe and effective technique for facilitating the healing of toe-deformity related diabetic ulcers. The aim of this review is to critically appraise the evidence for the effectiveness of this surgical procedure in achieving ulcer healing, prevention of re-ulceration, and to summarise the rate of post-operative complications. METHOD A search of medical databases, was performed to locate relevant literature. Titles were screened prior to abstract and full text review to identify articles relevant to the research question. Search terms included truncations of "tenotomy", "toe", "hallux", "digit", "diabetes" and "ulcer". Peer reviewed primary research study designs specified as suitable for systematic reviews by the Centre for Reviews and Dissemination were included. Studies were excluded if they used a concurrent secondary procedure or included non-diabetic patients without reporting outcomes separately. Included studies were appraised for quality using the Methodological Index for Non-Randomised Studies tool. Levels of evidence were subsequently assigned to each outcome of interest (healing rate and prevention of re-ulceration). RESULTS From a total search yield of 42 articles, 5 eligible studies (all case series designs) were identified for inclusion. Included studies were of low-to-moderate methodological quality when assessed using the MINORS tool. A total of 250 flexor tenotomy procedures were performed in a total of 163 patients. Included studies generally reported good healing rates (92-100 % within 2 months) post-op follow-up), relatively few recurrences (0-18 % at 22 months median post-op follow-up), and low incidences of infection or new deformity. Transfer ulcers developing on adjacent areas as a result of shifted pressure were reported by several authors. The validity of these results is undermined by methodological limitations inherent to case series designs such as a lack of control groups, non-randomised designs, as well as inconsistent reporting of post-intervention follow-up periods. There was level 4 evidence for the flexor tenotomy procedure in facilitating ulcer healing and preventing re-ulceration. CONCLUSION More definitive research evidence is needed in this area to determine whether or not the flexor tenotomy is a safe and effective treatment option for people with, or at risk of developing diabetic toe ulcers. Whilst the available literature reports that the procedure may be associated with high healing rates, relatively low recurrence rates and low incidences of post-op complications, methodological limitations restrict the value of these findings.
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Affiliation(s)
- Jennifer E. Scott
- School of Health and Life Sciences / Institute for Applied Health Research, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
| | - Gordon J. Hendry
- School of Health and Life Sciences / Institute for Applied Health Research, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
| | - John Locke
- School of Health and Life Sciences / Institute for Applied Health Research, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
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Lung CW, Hsiao-Wecksler ET, Burns S, Lin F, Jan YK. Quantifying Dynamic Changes in Plantar Pressure Gradient in Diabetics with Peripheral Neuropathy. Front Bioeng Biotechnol 2016; 4:54. [PMID: 27486576 PMCID: PMC4949238 DOI: 10.3389/fbioe.2016.00054] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/20/2016] [Indexed: 01/17/2023] Open
Abstract
Diabetic foot ulcers remain one of the most serious complications of diabetes. Peak plantar pressure (PPP) and peak pressure gradient (PPG) during walking have been shown to be associated with the development of diabetic foot ulcers. To gain further insight into the mechanical etiology of diabetic foot ulcers, examination of the pressure gradient angle (PGA) has been recently proposed. The PGA quantifies directional variation or orientation of the pressure gradient during walking and provides a measure of whether pressure gradient patterns are concentrated or dispersed along the plantar surface. We hypothesized that diabetics at risk of foot ulceration would have smaller PGA in key plantar regions, suggesting less movement of the pressure gradient over time. A total of 27 participants were studied, including 19 diabetics with peripheral neuropathy and 8 non-diabetic control subjects. A foot pressure measurement system was used to measure plantar pressures during walking. PPP, PPG, and PGA were calculated for four foot regions – first toe (T1), first metatarsal head (M1), second metatarsal head (M2), and heel (HL). Consistent with prior studies, PPP and PPG were significantly larger in the diabetic group compared with non-diabetic controls in the T1 and M1 regions, but not M2 or HL. For example, PPP was 165% (P = 0.02) and PPG was 214% (P < 0.001) larger in T1. PGA was found to be significantly smaller in the diabetic group in T1 (46%, P = 0.04), suggesting a more concentrated pressure gradient pattern under the toe. The proposed PGA may improve our understanding of the role of pressure gradient on the risk of diabetic foot ulcers.
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Affiliation(s)
- Chi-Wen Lung
- Rehabilitation Engineering Laboratory, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, IL, USA; Department of Creative Product Design, Asia University, Taichung, Taiwan
| | - Elizabeth T Hsiao-Wecksler
- Department of Mechanical Science and Engineering, University of Illinois at Urbana-Champaign , Urbana, IL , USA
| | - Stephanie Burns
- Department of Physical Therapy, Langston University , Langston, OK , USA
| | - Fang Lin
- Center for Lower Extremity Ambulatory Research, Rosalind Franklin University , North Chicago, IL , USA
| | - Yih-Kuen Jan
- Rehabilitation Engineering Laboratory, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign , Champaign, IL , USA
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The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg 2016; 63:3S-21S. [DOI: 10.1016/j.jvs.2015.10.003] [Citation(s) in RCA: 285] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 10/08/2015] [Indexed: 12/13/2022]
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Bus SA, van Netten JJ. A shift in priority in diabetic foot care and research: 75% of foot ulcers are preventable. Diabetes Metab Res Rev 2016; 32 Suppl 1:195-200. [PMID: 26452160 DOI: 10.1002/dmrr.2738] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/20/2015] [Accepted: 09/20/2015] [Indexed: 12/20/2022]
Abstract
Diabetic foot ulceration poses a heavy burden on the patient and the healthcare system, but prevention thereof receives little attention. For every euro spent on ulcer prevention, ten are spent on ulcer healing, and for every randomized controlled trial conducted on prevention, ten are conducted on healing. In this article, we argue that a shift in priorities is needed. For the prevention of a first foot ulcer, we need more insight into the effect of interventions and practices already applied globally in many settings. This requires systematic recording of interventions and outcomes, and well-designed randomized controlled trials that include analysis of cost-effectiveness. After healing of a foot ulcer, the risk of recurrence is high. For the prevention of a recurrent foot ulcer, home monitoring of foot temperature, pressure-relieving therapeutic footwear, and certain surgical interventions prove to be effective. The median effect size found in a total of 23 studies on these interventions is large, over 60%, and further increases when patients are adherent to treatment. These interventions should be investigated for efficacy as a state-of-the-art integrated foot care approach, where attempts are made to assure treatment adherence. Effect sizes of 75-80% may be expected. If such state-of-the-art integrated foot care is implemented, the majority of problems with foot ulcer recurrence in diabetes can be resolved. It is therefore time to act and to set a new target in diabetic foot care. This target is to reduce foot ulcer incidence with at least 75%.
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Affiliation(s)
- Sicco A Bus
- Department of Rehabilitation Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
| | - Jaap J van Netten
- Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
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Caravaggi P, Giangrande A, Berti L, Lullini G, Leardini A. Pedobarographic and kinematic analysis in the functional evaluation of two post-operative forefoot offloading shoes. J Foot Ankle Res 2015; 8:59. [PMID: 26516351 PMCID: PMC4625618 DOI: 10.1186/s13047-015-0116-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 10/21/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Forefoot offloading shoes are special orthopaedic footwear designed to protect and unload the injured part of the foot after surgery and for conservative treatments. The offloading action is often achieved by transferring plantar load to the rearfoot via rocker shoes with reduced contact area between shoe and ground. While these shoes are intended to be worn only for short periods, a compromise must be found between functionality and the risk of alterations in gait patterns at the lower limb joints. In this study, the pedobarographic, kinematic and kinetic effects of a traditional half-shoe and a double-rocker full-outsole shoe were compared to those of a comfortable shoe (control). METHODS Ten healthy female participants (28.2 ± 10.0 years) were asked to walk in three different footwear conditions for the left/right foot: control/half-shoe, control/full-outsole, and control/control. Full gait analysis was obtained in three walking trials for each participant in each condition. Simultaneously a sensor insole system recorded plantar pressure in different foot regions. Normalized root-mean-square error, coefficient of determination, and frame-by-frame statistical analysis were used to assess differences in time-histories of kinematic and kinetic parameters between shoes. RESULTS The half -shoe group showed the slowest walking speed and the shortest stride length. Forefoot plantar load was significantly reduced in the half-shoe (maximum force as % of Body Weight: half-shoe = 62.1; full-outsole = 86.9; control = 93.5; p < 0.001). At the rearfoot, mean pressure was the highest in the full-outsole shoe. At the ankle, sagittal-plane kinematics in the full-outsole shoe had a pattern more similar to control. CONCLUSIONS The half-shoe appears significantly more effective in reducing plantar load at the forefoot than a double-rocker full-outsole shoe, which is designed to reduce forefoot loading by using an insole with a thicker profile anteriorly as to maintain the foot in slight dorsiflexion. However, the half-shoe is also associated with altered gait spatio-temporal parameters, more kinematic modifications at the proximal lower limb joints and reduced propulsion in late stance.
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Affiliation(s)
- Paolo Caravaggi
- Movement Analysis Laboratory and Functional-Clinical Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Alessia Giangrande
- Movement Analysis Laboratory and Functional-Clinical Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Lisa Berti
- Movement Analysis Laboratory and Functional-Clinical Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Giada Lullini
- Movement Analysis Laboratory and Functional-Clinical Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Alberto Leardini
- Movement Analysis Laboratory and Functional-Clinical Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
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Wafai L, Zayegh A, Woulfe J, Aziz SM, Begg R. Identification of Foot Pathologies Based on Plantar Pressure Asymmetry. SENSORS 2015; 15:20392-408. [PMID: 26295239 PMCID: PMC4570427 DOI: 10.3390/s150820392] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 08/07/2015] [Accepted: 08/11/2015] [Indexed: 11/16/2022]
Abstract
Foot pathologies can negatively influence foot function, consequently impairing gait during daily activity, and severely impacting an individual’s quality of life. These pathologies are often painful and correspond with high or abnormal plantar pressure, which can result in asymmetry in the pressure distribution between the two feet. There is currently no general consensus on the presence of asymmetry in able-bodied gait, and plantar pressure analysis during gait is in dire need of a standardized method to quantify asymmetry. This paper investigates the use of plantar pressure asymmetry for pathological gait diagnosis. The results of this study involving plantar pressure analysis in fifty one participants (31 healthy and 20 with foot pathologies) support the presence of plantar pressure asymmetry in normal gait. A higher level of asymmetry was detected at the majority of the regions in the feet of the pathological population, including statistically significant differences in the plantar pressure asymmetry in two regions of the foot, metatarsophalangeal joint 3 (MPJ3) and the lateral heel. Quantification of plantar pressure asymmetry may prove to be useful for the identification and diagnosis of various foot pathologies.
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Affiliation(s)
- Linah Wafai
- College of Engineering and Science, Victoria University, Melbourne VIC-3032, Australia.
| | - Aladin Zayegh
- College of Engineering and Science, Victoria University, Melbourne VIC-3032, Australia.
| | - John Woulfe
- Boronia Podiatry, Melbourne VIC-3155, Australia.
| | - Syed Mahfuzul Aziz
- School of Engineering, University of South Australia, Mawson Lakes SA-5095, Australia.
| | - Rezaul Begg
- Gait and Balance Research Group, Institute of Sport, Exercise and Active Living (ISEAL), Victoria University, Melbourne VIC-3032, Australia.
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Al Bagdhadi J, Chong A, Milburn P. Matching stress and strain on the foot during the loading phase of gait. FOOTWEAR SCIENCE 2015. [DOI: 10.1080/19424280.2015.1038608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Song Q, Xu K, Yu B, Zhang C, Sun W, Mao D. Could Insoles Offload Pressure? An Evaluation of the Effects of Arch-supported Functional Insoles on Plantar Pressure Distribution during Race Walking. Res Sports Med 2015; 23:278-88. [DOI: 10.1080/15438627.2015.1040913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Qipeng Song
- Shanghai University of Sport, Shanghai, China
| | - Kaisheng Xu
- Shanghai University of Sport, Shanghai, China
| | - Bing Yu
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Cui Zhang
- Shandong Sports Science Research Center, Jinan, Shandong, China
| | - Wei Sun
- Shandong Sports Science Research Center, Jinan, Shandong, China
| | - Dewei Mao
- Shanghai University of Sport, Shanghai, China
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Predictors of barefoot plantar pressure during walking in patients with diabetes, peripheral neuropathy and a history of ulceration. PLoS One 2015; 10:e0117443. [PMID: 25647421 PMCID: PMC4315609 DOI: 10.1371/journal.pone.0117443] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 12/24/2014] [Indexed: 12/02/2022] Open
Abstract
Objective Elevated dynamic plantar foot pressures significantly increase the risk of foot ulceration in diabetes mellitus. The aim was to determine which factors predict plantar pressures in a population of diabetic patients who are at high-risk of foot ulceration. Methods Patients with diabetes, peripheral neuropathy and a history of ulceration were eligible for inclusion in this cross sectional study. Demographic data, foot structure and function, and disease-related factors were recorded and used as potential predictor variables in the analyses. Barefoot peak pressures during walking were calculated for the heel, midfoot, forefoot, lesser toes, and hallux regions. Potential predictors were investigated using multivariate linear regression analyses. 167 participants with mean age of 63 years contributed 329 feet to the analyses. Results The regression models were able to predict between 6% (heel) and 41% (midfoot) of the variation in peak plantar pressures. The largest contributing factor in the heel model was glycosylated haemoglobin concentration, in the midfoot Charcot deformity, in the forefoot prominent metatarsal heads, in the lesser toes hammer toe deformity and in the hallux previous ulceration. Variables with local effects (e.g. foot deformity) were stronger predictors of plantar pressure than global features (e.g. body mass, age, gender, or diabetes duration). Conclusion The presence of local deformity was the largest contributing factor to barefoot dynamic plantar pressure in high-risk diabetic patients and should therefore be adequately managed to reduce plantar pressure and ulcer risk. However, a significant amount of variance is unexplained by the models, which advocates the quantitative measurement of plantar pressures in the clinical risk assessment of the patient.
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Robinson C, Major MJ, Kuffel C, Hines K, Cole P. Orthotic management of the neuropathic foot: an interdisciplinary care perspective. Prosthet Orthot Int 2015; 39:73-81. [PMID: 25614503 DOI: 10.1177/0309364614545422] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Clinical management of the patient with neuropathic foot is becoming commonplace in orthotic clinics worldwide. The presentations that can result from neuropathic foot are diverse, requiring clinicians to understand the pathomechanics of ulceration, infection, and Charcot joint arthropathy to provide effective interventions. OBJECTIVES The purpose of this clinical perspective is to provide a review of the literature regarding clinical concepts associated with orthotic management of neuropathic foot. STUDY DESIGN Literature review and clinical case study. METHODS Relevant literature were reviewed and summarized, and a clinical case study synthesizing reviewed concepts was presented. RESULTS Given the multifactorial nature of the neuropathic foot, treatments must be multifaceted and patient-specific to effectively address the underlying disease processes. While systemic issues such as peripheral arterial disease are treated by physicians, local issues such as foot deformity are managed by orthotists. Orthotic interventions commonly include custom footwear to reduce the risk of ulceration through creation of a protective environment or targeted plantar offloading. Patient and caregiver education to encourage management compliance is equally as important to ensure successful treatment. CONCLUSION Patients with neuropathic foot benefit from an interdisciplinary care approach which engages physicians, wound care practitioners, and orthotists to treat and manage systemic and local problems. Addressing this pathology through interdisciplinary care may positively affect the patient's health status while lowering associated healthcare costs through improved treatment efficacy. CLINICAL RELEVANCE The commonality of neuropathic foot and associated complications including ulceration, infection, and Charcot joint arthropathy requires that the patient care team have a fundamental understanding of these pathologies and common treatment modalities. We review orthotic treatment modalities to assist clinicians with the management of patients with neuropathic foot.
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Affiliation(s)
| | - Matthew J Major
- Jesse Brown VA Medical Center, Northwestern University, Chicago, IL, USA
| | | | - Kevin Hines
- Arise Orthotics & Prosthetics, Inc., Blaine, MN, USA
| | - Pamela Cole
- Methodist Hospital Wound Clinic, St. Louis Park, MN, USA
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