Diabetic foot off loading and ulcer remission: Exploring surgical off-loading

A retrospective cohort study on enhanced recovery after surgery (ERAS) in patients with diabetic foot ulcer

Enhanced recovery after surgery (ERAS) has been successfully integrated into a diverse array of surgical fields to improve the quality and efficacy of treatment intervention. Nonetheless, the application of the ERAS protocol for patients with diabetic foot ulcer (DFU) subsequent to undergoing surgical procedures has not been previously explored. Therefore, this study aimed to investigate the effect of an enhanced recovery protocol on perioperative outcomes in patients with DFU following surgical procedures. A retrospective analysis was conducted on 112 patients with DFU who underwent surgery between January 2020 and December 2021 at a tertiary referral care center. In total, 57 patients received standard perioperative care (the non-ERAS group), and 55 patients received ERAS care (the ERAS group). The primary outcomes included the length of stay (LOS), wound healing time, patient satisfaction, and costs, serving as the basis for assessing the effectiveness of the two approaches. Secondary outcomes included preoperative anxiety (APAIS score), nutritional status (PG-SGA), pain (NRS score), the incidence of lower-extremity deep vein thrombosis (DVT), the reduction in lower-limb circumference, and the activity of daily living scale (Barthel Index). The ERAS group exhibited significantly shorter LOS (11.36 vs. 26.74 days; P < 0.001) and lower hospital costs (CNY 62,165.27 vs. CNY 118,326.84; P < 0.001), as well as a higher patient satisfaction score and Barthel Index score (P < 0.05). Additionally, we found a lower APAIS score, incidence of DVT, and circumference reduction in lower limbs in the ERAS group compared to the non-ERAS group (P < 0.05). In comparison, the wound healing time, nutritional status, and pain levels of participants in both groups showed no significant difference (P > 0.05). By reducing the LOS and hospital costs, and by minimizing perioperative complications, the ERAS protocol improves the quality and efficacy of treatment intervention in patients with DFU who underwent surgical procedures.Trial registration number: ChiCTR 2200064223 (Registration Date: 30/09/2022).

Unveiling therapeutic potential: Adipose tissue-derived mesenchymal stem cells and their exosomes in the management of diabetes mellitus, wound healing, and chronic ulcers

Diabetes mellitus (DM) is a pervasive global health issue with substantial morbidity and mortality, often resulting in secondary complications, including diabetic wounds (DWs). These wounds, arising from hyperglycemia, diabetic neuropathy, anemia, and ischemia, afflict approximately 15% of diabetic patients, with a considerable 25% at risk of lower limb amputations. The conventional approaches for chronic and diabetic wounds management involves utilizing various therapeutic substances and techniques, encompassing growth factors, skin substitutes and wound dressings. In parallel, emerging cell therapy approaches, notably involving adipose tissue-derived mesenchymal stem cells (ADMSCs), have demonstrated significant promise in addressing diabetes mellitus and its complications. ADMSCs play a pivotal role in wound repair, and their derived exosomes have garnered attention for their therapeutic potential. This review aimed to unravel the potential mechanisms and provide an updated overview of the role of ADMSCs and their exosomes in diabetes mellitus and its associated complications, with a specific focus on wound healing.

Phytoconstituents as modulators of NF-κB signalling: Investigating therapeutic potential for diabetic wound healing

The NF-κB pathway plays a pivotal role in impeding the diabetic wound healing process, contributing to prolonged inflammation, diminished angiogenesis, and reduced proliferation. In contrast to modern synthetic therapies, naturally occurring phytoconstituents are well-studied inhibitors of the NF-κB pathway that are now attracting increased attention in the context of diabetic wound healing because of lower toxicity, better safety and efficacy, and cost-effectiveness. This study explores recent research on phytoconstituent-based therapies and delve into their action mechanisms targeting the NF-κB pathway and potential for assisting effective healing of diabetic wounds. For this purpose, we have carried out surveys of recent literature and analyzed studies from prominent databases such as Science Direct, Scopus, PubMed, Google Scholar, EMBASE, and Web of Science. The classification of phytoconstituents into various categorie such as: alkaloids, triterpenoids, phenolics, polyphenols, flavonoids, monoterpene glycosides, naphthoquinones and tocopherols. Noteworthy phytoconstituents, including Neferine, Plumbagin, Boswellic acid, Genistein, Luteolin, Kirenol, Rutin, Vicenin-2, Gamma-tocopherol, Icariin, Resveratrol, Mangiferin, Betulinic acid, Berberine, Syringic acid, Gallocatechin, Curcumin, Loureirin-A, Loureirin-B, Lupeol, Paeoniflorin, and Puerarin emerge from these studies as promising agents for diabetic wound healing through the inhibition of the NF-κB pathway. Extensive research on various phytoconstituents has revealed how they modulate signalling pathways, including NF-κB, studies that demonstrate the potential for development of therapeutic phytoconstituents to assist healing of chronic diabetic wounds.

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

AIM

To compare the effectiveness of commonly used offloading devices for the treatment of neuropathic foot ulcers in patients with diabetes mellitus. This meta-analysis (MA) has been performed for giving an answer to clinical questions on this topic of the Italian guideline on diabetic foot syndrome.

METHODS

The present MA includes randomized controlled studies (duration > 12 weeks) comparing, in patients with diabetes mellitus and non-infected neuropathic foot ulcer: any offloading device vs either no offloading device or conventional footwear; removable versus non-removable offloading devices; surgical procedure vs other offloading approaches. The primary endpoint was ulcer healing.

RESULTS

A total of 184 studies were identified, and 18 were considered eligible for the analysis. We found that: any plantar off-loading, when compared to the absence of plantar offloading device, is associated with a higher ulcer healing (MH-OR: 3.13 [1.08, 9.11], p = 0.04, I2 = 0%); total contact cast or nonremovable knee-high walker, compared to other offloading devices, had a higher ulcer healing rate (MH-OR: 2.64 [1.43, 4.89], p = 0.002, I2 = 51%); surgical offloading for active ulcers in combination with post-surgery offloading achieves higher ulcer healing rate when compared to offloading devices alone (MH-OR: 6.77 [1.64, 27.93], p = 0.008, I2 = 0%).

CONCLUSIONS

Any plantar offloading, compared to the absence of plantar offloading device, is associated with a higher ulcer healing rate. Total contact cast or nonremovable knee-high walker, compared to other offloading devices, is preferable. Surgical offloading for active ulcers, in combination with post-surgery offloading devices, achieves a higher ulcer healing rate when compared to other offloading devices alone. Further studies with a larger cohort of patients with diabetic neuropathic foot ulcers and extended follow-up periods are necessary.

Insights into the mechanisms of diabetic wounds: pathophysiology, molecular targets, and treatment strategies through conventional and alternative therapies

Diabetes mellitus is a prevalent cause of mortality worldwide and can lead to several secondary issues, including DWs, which are caused by hyperglycemia, diabetic neuropathy, anemia, and ischemia. Roughly 15% of diabetic patient's experience complications related to DWs, with 25% at risk of lower limb amputations. A conventional management protocol is currently used for treating diabetic foot syndrome, which involves therapy using various substances, such as bFGF, pDGF, VEGF, EGF, IGF-I, TGF-β, skin substitutes, cytokine stimulators, cytokine inhibitors, MMPs inhibitors, gene and stem cell therapies, ECM, and angiogenesis stimulators. The protocol also includes wound cleaning, laser therapy, antibiotics, skin substitutes, HOTC therapy, and removing dead tissue. It has been observed that treatment with numerous plants and their active constituents, including Globularia Arabica, Rhus coriaria L., Neolamarckia cadamba, Olea europaea, Salvia kronenburgii, Moringa oleifera, Syzygium aromaticum, Combretum molle, and Myrtus communis, has been found to promote wound healing, reduce inflammation, stimulate angiogenesis, and cytokines production, increase growth factors production, promote keratinocyte production, and encourage fibroblast proliferation. These therapies may also reduce the need for amputations. However, there is still limited information on how to prevent and manage DWs, and further research is needed to fully understand the role of alternative treatments in managing complications of DWs. The conventional management protocol for treating diabetic foot syndrome can be expensive and may cause adverse side effects. Alternative therapies, such as medicinal plants and green synthesis of nano-formulations, may provide efficient and affordable treatments for DWs.

Ambulatory Status before Diabetic Foot Ulcer Development as a Predictor of Amputation and 1-Year Outcomes: A Retrospective Analysis

Background

Up to 25% of people with diabetes develop a diabetic foot ulcer (DFU) during their lifetime, which precedes approximately 85% of nontraumatic lower limb amputations. Diabetic limb salvage has been at the forefront of recent research, as major amputation is associated with 5-year mortality rates of 52%-80%. We sought to determine if ambulatory status before DFU diagnosis is predictive of amputations and outcomes within 1 year, as no studies have directly examined this relationship.

Methods

A retrospective review of patients diagnosed with DFUs from January 2011 to December 2021 was performed. Patients aged 18 years or more with type II diabetes were included. Ambulatory status was defined as the primary form of mobility reported by the patient before development of DFU, and was categorized as independent ambulation, ambulatory with assisting device (AWAD), or nonambulatory (NA). Statistical analyses included χ2, multinomial, and multivariable logistic regressions.

Results

After review, 506 patients were included. NA (OR = 5.10; P = 0.002) and AWAD status (OR = 2.77; P = 0.01) before DFU development were predictive of major (below or above-knee) amputation during hospitalization, emergency department visits within 30-days (NA: OR = 4.19; P = 0.01, AWAD: OR = 3.09; P = 0.02), and mortality within one-year (NA: OR = 4.19; P = 0.01, AWAD: OR = 3.09; P = 0.02). AWAD status was also associated with increased risk of hospital readmission (OR = 2.89; P < 0.001) within 30-days and any amputation (OR = 1.73; P = 0.01) within 1 year.

Conclusions

In patients with DFUs, NA and AWAD status were predictive of major amputation during hospitalization and are associated with poorer 1-year outcomes, including mortality. Ambulatory status assessment may be used to inform DFU treatment approaches.

A 2-Stage Approach in Managing Diabetic Forefoot Ulcers

BACKGROUND

Forefoot plantar ulcers in patients with diabetic neuropathy are considered to be primarily the result of increased shear forces applied over prominent plantar bony prominences. The purpose of this article is to describe a 2-stage treatment pathway utilizing an outpatient percutaneous tendon-Achilles lengthening (TAL) as the first stage procedure and subsequent proximal metatarsal osteotomy (MTO) as a second stage procedure for a persistent or recurrent ulcer.

METHODS

A consecutive 112 patients (146 feet), who presented to our Multidisciplinary Diabetic Foot Team clinics since February 2019 with plantar nonischemic forefoot ulcers were included in this study. Excluding the patients who died or were lost to follow-up, 96 feet were followed for a minimum 12 months (range 12-36 months). After TAL, patients were encouraged to walk in a walking cast for 6 weeks and were followed for a minimum 12 months. Patients with persistent or recurrent ulcers were investigated with magnetic resonance imaging scan, and based on intramedullary osteomyelitis and septic destruction of distal metatarsal, we describe a second-stage MTO with the 3 most common clinical presentations.

RESULTS

Of 96 feet, none had infection or wound-related problems following TAL. Complete transection of the tendon was noted in 4 patients (4%) and heel callosity in 1 patient. In 92 feet (96%), the ulcers healed within 10 weeks (±4 weeks) after TAL but, in 12 feet (10%), the ulcer failed to heal or recurred. At a minimum 12 months after the second-stage MTO, none in this subgroup had recurrence of ulcer or a transfer lesion.

CONCLUSION

TAL followed with a walking cast as an outpatient procedure was effective in healing forefoot ulcers in 96% of feet. Comparable to the widely practiced hand surgery Wide Awake Local Anesthesia No Tourniquet (WALANT) procedure, our approach involved active control of the degree of ankle dorsiflexion by the patient, and the procedure was proven to be safe and well tolerated. When the second-stage MTO was required to offload the forefoot, in our small cohort, patients had ulcer-free outcome for a minimum 12 months.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Cerium oxide nanoparticles in diabetic foot ulcer management: Advances, limitations, and future directions

Diabetic foot ulcer (DFU) is one of the most serious complications of diabetes, potentially resulting in wound infection and amputation under severe circumstances. Oxidative stress and dysbiosis are the primary factors that delay wound healing, posing challenges to effective treatment. Unfortunately, conventional approaches in these aspects have proven satisfactory in achieving curative outcomes. Recent research has increasingly focused on using nanoparticles, leveraging their potential in wound dressing and medication delivery. Their unique physical properties further enhance their therapeutic effectiveness. Among these nanoparticles, cerium oxide nanoparticles (CONPs) have garnered attention due to their notable beneficial effects on oxidative stress and microbial abundance, thus representing a promising therapeutic avenue for DFU. This review comprehensively assesses recent studies on CONPs in treating DFU. Furthermore, we elaborate on the wound healing process, ceria synthesis, and incorporating CONPs with other materials. Crucially, a thorough evaluation of CONPs' toxicity as a novel metallic nanomaterial for therapeutic use must precede their formal clinical application. Additionally, we identify the current challenges CONPs encounter and propose future directions for their development.

Adipose-derived stem cell exosome NFIC improves diabetic foot ulcers by regulating miR-204-3p/HIPK2

BACKGROUND

Diabetic foot ulcers (DFU) are a serious complication of diabetes that lead to significant morbidity and mortality. Recent studies reported that exosomes secreted by human adipose tissue-derived mesenchymal stem cells (ADSCs) might alleviate DFU development. However, the molecular mechanism of ADSCs-derived exosomes in DFU is far from being addressed.

METHODS

Human umbilical vein endothelial cells (HUVECs) were induced by high-glucose (HG), which were treated with exosomes derived from nuclear factor I/C (NFIC)-modified ADSCs. MicroRNA-204-3p (miR-204-3p), homeodomain-interacting protein kinase 2 (HIPK2), and NFIC were determined using real-time quantitative polymerase chain reaction. Cell proliferation, apoptosis, migration, and angiogenesis were assessed using cell counting kit-8, 5-ethynyl-2'-deoxyuridine (EdU), flow cytometry, wound healing, and tube formation assays. Binding between miR-204-3p and NFIC or HIPK2 was predicted using bioinformatics tools and validated using a dual-luciferase reporter assay. HIPK2, NFIC, CD81, and CD63 protein levels were measured using western blot. Exosomes were identified by a transmission electron microscope and nanoparticle tracking analysis.

RESULTS

miR-204-3p and NFIC were reduced, and HIPK2 was enhanced in DFU patients and HG-treated HUVECs. miR-204-3p overexpression might abolish HG-mediated HUVEC proliferation, apoptosis, migration, and angiogenesis in vitro. Furthermore, HIPK2 acted as a target of miR-204-3p. Meanwhile, NFIC was an upstream transcription factor that might bind to the miR-204-3p promoter and improve its expression. NFIC-exosome from ADSCs might regulate HG-triggered HUVEC injury through miR-204-3p-dependent inhibition of HIPK2.

CONCLUSION

Exosomal NFIC silencing-loaded ADSC sheet modulates miR-204-3p/HIPK2 axis to suppress HG-induced HUVEC proliferation, migration, and angiogenesis, providing a stem cell-based treatment strategy for DFU.

Efficacy and safety of autologous platelet-rich plasma for diabetic foot ulcer healing: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The occurrence of a diabetic foot ulcer (DFU) is a significant complication of diabetes that often precedes the need for amputation. Autologous platelet-rich plasma (Au-PRP), a substance abundant in various growth factors and cytokines, is increasingly being recognized as a promising method for promoting ulcer healing due to its potential similarities to the physiological wound healing process.

METHODS

The databases Medline, EMBASE, PubMed, and the Cochrane Library were systematically accessed on January 26, 2023, without any consideration for the date of publication. The selection and assessment of research studies were conducted autonomously, based on predetermined criteria and methodological standards. Two researchers gathered data and evaluated the potential for bias separately. We utilize the Stata 17.0 software to conduct data analysis and generate relevant visual representations.

RESULTS

The results of the meta-analysis indicate that autologous PRP has a significant positive effect on the healing rate (RR = 1.42, 95% CI 1.30-1.56, P < 0.001), reduces the healing time (MD = - 3.13, 95% CI - 5.86 to - 0.39, P < 0.001), accelerates the reduction of ulcer area (MD = 1.02, 95% CI 0.51-1.53, P < 0.001), decreases the rate of amputation (RR = 0.35, 95% CI 0.15-0.83, P < 0.001), and does not increase the incidence of adverse events (RR = 0.96, 95% CI 0.57-1.61, P > 0.05) when compared to conventional therapy.

CONCLUSIONS

Au-PRP therapy has been shown to facilitate the process of wound healing and represents a viable and secure therapeutic alternative for individuals with DFU.

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

BACKGROUND

Hallux ulcers are known for their recurrence and associated risk for future amputations. Traditional nonsurgical external offloading methods have poor compliance rates, and the data is sparse on surgical offloading of hallux ulcers. We performed this study to analyze the outcomes of Keller excision gap arthroplasty of the first metatarsophalangeal joint in patients with a neuropathic plantar hallux interphalangeal joint (IPJ) ulcer in patients with diabetes mellitus.

METHODS

A retrospective study of 105 diabetic patients with a plantar hallux IPJ ulcer who underwent a Keller excision gap arthroplasty between December 2014 and June 2020 was done. A total of 122 great toes had been operated upon for hallux IPJ ulcers. We studied the long-term wound healing rates from patient records and then did a prospective survey of the postreview period.

RESULTS

All the hallux IPJ ulcers healed well in the immediate postoperative period. Six patients reported a recurrence of the ulcer at the original site during a mean follow-up period of 30 months. For these 6 patients, the mean time to recurrence of ulcer after operation was 2.5 years.

CONCLUSION

At an average of 30 months, we found the Keller gap arthroplasty for treatment of noninfected and nonischemic diabetic foot hallux IPJ ulcers was associated with an ulcer recurrence rate of 5%.

LEVEL OF EVIDENCE

Level IV, cohort study.

Diabetic foot ulcers: A devastating complication of diabetes mellitus continues non-stop in spite of new medical treatment modalities

Diabetic foot ulcer is a devastating complication of diabetes mellitus and significant cause of mortality and morbidity all over the world and can be complex and costly. The development of foot ulcer in a diabetic patient has been estimated to be 19%-34% through their lifetime. The pathophysiology of diabetic foot ulcer consist of neuropathy, trauma and, in many patients, additional peripheral arterial disease. In particular, diabetic neuropathy leads to foot deformity, callus formation, and insensitivity to trauma or pressure. The standard algorithms in diabetic foot ulcer management include assessing the ulcer grade classification, surgical debridement, dressing to facilitate wound healing, off-loading, vascular assessment (status and presence of a chance for interventional vascular correction), and infection and glycemic control. Although especially surgical procedures are sometimes inevitable, they are poor predictive factors for the prognosis of diabetic foot ulcer. Different novel treatment modalities such as nonsurgical debridement agents, oxygen therapies, and negative pressure wound therapy, topical drugs, cellular bioproducts, human growth factors, energy-based therapies, and systematic therapies have been available for patients with diabetic foot ulcer. However, it is uncertain whether they are effective in terms of promoting wound healing related with a limited number of randomized controlled trials. This review aims at evaluating diabetic foot ulcer with regard to all aspects. We will also focus on conventional and novel adjunctive therapy in diabetic foot management.

Diabetic foot ulcers: Classification, risk factors and management

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.

Diabetic foot ulcer: Challenges and future

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.

Comparative analysis of bone consolidation chronology in claw toes operated through minimal invasive osteotomies in diabetic vs. non-diabetic patients

Objective

To compare bone healing time in osteotomies performed in claw toes correction through minimal invasive surgery in diabetic vs. non-diabetic patients. The relation between the patient's ages and the American Orthopedic Foot and Ankle Surgery Society (AOFAS) functional scores before and after surgery was also analyze in the two types of patients.

Method

A series of 45 women, 23 of them suffering from Diabetes Mellitus, were operated to correct claw toes. The surgery was always performed through minimal invasive digital osteotomies. After the intervention, bone healing was controlled by a fluoroscopic weekly follow-up until a complete bone consolidation was reached. Bone healing time was compared in in two groups of patients, diabetic and non-diabetic. All patients were evaluated with AOFAS scale 48 h before and 90 days after the intervention.

Results

The time of bone healing ranged from 24 to 40 days after the surgery and took shorter time of consolidation in non-diabetic patients although the Mann Withney U test did not show statistically significant differences (p = 0,409, effect size (ES) = 0,14 [-0.20 to 0.45]) between both groups. A statistically significant association (r = 0.71, R ²= 50%, p < 0.001) was found between the healing days and the day of medical discharge, also between the ages of the patients and the medial discharge (r = 0.36, R ²= 13%, p < 0.001). However, no statistically significant associations were found between pre-intervention glycemia and days of bone consolidation, neither in medical discharge (r = 0.07, p = 0.646 y r = 0.07, p = 0.648, respectively). AOFAS test scores and the diabetes status showed statistically significant differences, both in the main effect of Diabetes (F_[1,41]= 9.41, p = 0.004) as in the interaction between diabetes and age (F_[1,41]= 9.17, p = 0.004).

Conclusions

The bone healing time in claw toes operated through minimal invasive osteotomy surgery is not influenced by the presence of diabetes. The consolidation speed and the improvement in AOFAS functional scale score post-surgery in diabetic and elder patients was related to duration of the medical discharge.

Are Digital Arthroplasty and Arthrodesis Useful and Safe Surgical Techniques for the Management of Patients with Diabetic Foot?

OBJECTIVE

To analyze and compare the development of short- and long-term complications in patients with diabetic foot after digital arthroplasty or arthrodesis.

METHODS

The authors reviewed patient records from January 2017 to March 2020. Patients were treated by digital arthroplasty or arthrodesis to correct toe deformity (elective or prophylactic surgery), achieve ulcer healing in toes (curative surgery), or manage toe infection (emergent surgery). During 1-year follow-up, researchers registered short- and long-term complications. Researchers analyzed the association between the type of surgery and the development of short- and long-term complications.

RESULTS

Forty-four patients (83.0%) received arthroplasty, and nine (17.0%) received arthrodesis. The mean time to heal from ulcers was 5.2 ± 5.2 weeks. A significant association was observed between arthrodesis and the development of long-term complications (P = .044; odds ratio, 5.1; 95% confidence interval, 0.9-27.2). No differences were observed between type of surgery and short- or long-term complications. Moreover, both short- and long-term complications were related to longer time to heal (respectively, 7.6 ± 6.0 vs 2.1 ± 0.5 weeks, P < .001; and 6.3 ± 6.2 vs 4.2 ± 4.0 weeks, P = .039).

CONCLUSIONS

Digital arthroplasty or arthrodesis are good options for managing patients with diabetic foot who require digital deformity correction to achieve digital ulcer healing or management of diabetic foot infection in phalanges.

A Cohort Study to Compare Effects between Ulcer- and Nonulcer-Related Nonvariceal Upper Gastrointestinal Bleeding

Objective

The aim of this study was to better understand the characteristics and etiology of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) in recent years in this region and to provide evidence-based medical evidence.

Methods

100 patients with acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) who met the clinical diagnostic criteria of ANVUGIB admitted to Suzhou First People's Hospital from January 2017 to December 2021 were analyzed, as well as the age difference and change rule. According to age, 100 patients were divided into young (18-39 years), middle-aged (40-59 years), and elderly (60 years and above), and the differences in the three groups were compared. The etiology was confirmed by endoscopic examination and was recorded one by one in a well-designed ANVUGIB case data registration form. Statistical software SPSS 23.0 was used for analysis.

Results

Gastric ulcer was the main cause in the elderly group (50.0%), duodenal ulcer was the main cause in the middle and young groups, and gastrointestinal cancer (7.1%) and marginal ulcer (2.3%) in the elderly group were higher than those in the young group. Nonsteroidal anti-inflammatory drugs (52.3%) were the main inducement in the elderly group, which was significantly higher than in the middle-aged group (13.1%) and the young group (5%) (P < 0.01). Drinking, fatigue, and emotional excitement led to a higher proportion in the middle-aged group and the young group, in comparison to the elderly group (P < 0.01).

Conclusion

Peptic ulcer is the most common cause of acute nonvariceal upper gastrointestinal bleeding, followed by acute gastric mucosal lesions and upper digestive system tumors, compared with nonulcer.

Impairment characteristics of static balance and plantar load distribution of patients undergoing tibial cortex transverse distraction for diabetic foot ulcers

Objective

Tibial cortex transverse distraction (TCTD) has been recently reported for the treatment of diabetic foot ulcers. Herein, we explored the characteristics of the impairments in static balance and plantar load distribution in patients.

Methods

We performed a retrospective study of 21 patients with diabetic foot ulcers who underwent TCTD, who were regularly followed up for > 1 year after surgery, and 20 healthy individuals (control group). A pressure platform was used to assess the standing balance functions of the lower extremities and the plantar load distribution.

Results

One patient underwent amputation because of severe infection. In patient group, center of pressure (COP) ellipse sway area, COP path length and angle θ were all larger, compared with those of control group (250.15 ± 98.36 mm² vs. 135.67 ± 53.21 mm², 145.15 ± 67.43 mm vs. 78.47 ± 34.15 mm, 39.75 ± 17.61° vs. 22.17 ± 14.15°), with statistically significant differences (P < 0.01). The average plantar load and backfoot load of the unaffected side was significantly larger than that of the affected side (58.4 ± 5.5% vs. 41.6 ± 5.5%, 45.3 ± 6.4% vs. 36.5 ± 5.6%), but they were similar for the two feet of members of the control group.

Conclusions

Although TCTD may represent an appropriate method for the treatment of diabetic foot ulcers, postoperative impairments in static balance and plantar load distribution remain in the long term. These potential long-term problems should be taken into account in further rehabilitation planning.

Type of study/level of evidence: Therapeutic III.

Foot Burns in Persons with Diabetes—Outcomes from the National Trauma Data Bank

Diabetes Mellitus (DM) complicates the treatment of burn injuries. Foot burns in diabetic patients are challenging problems with unfavorable outcomes. National-scale evaluations are needed, especially with regard to limb salvage. We aim to characterize lower extremity burns in persons with DM and evaluate the likelihood of amputation. The National Trauma Data Bank (NTDB) was queried from 2007-2015 extracting encounters with primary burn injuries of the feet using International Classification of Diseases (ICD) 9 th Edition codes. Logistic regression modeled predictors of lower extremity amputation. Covariables included age, sex, race/ethnicity, comorbidities including DM, % burn total body surface area (TBSA), mechanism, and region of burn center. Poisson regression evaluated temporal incidence rate changes in DM foot burns. Of 116,796 adult burn encounters, 7,963 (7%) had foot burns. Of this group, 1,308 (16%) had DM. 5.6% of encounters with DM foot burns underwent amputation compared to 1.5% of non-DM encounters (p&lt;0.001). Independent predictors of lower extremity amputation included DM (OR 3.70, 95% CI 2.98 – 4.59), alcohol use, smoking, chronic kidney disease, burn size &gt;20%, African American/Black race, male sex, and age&gt;40 years (all p&lt;0.01). The incidence of DM foot burns increased over the study period with an incidence rate ratio (IRR) of 1.07 (95% CI 1.05 – 1.10, p&lt;0.001). In conclusion, DM was associated with nearly a 4-fold increase in amputation after adjusting for covariables. Furthermore, the incidence of DM foot burns is increasing. Strategies for optimizing care in persons with DM foot burns are need to improve limb salvage.

Diabetic Wound-Healing Science

Diabetes mellitus is an increasingly prevalent chronic metabolic disease characterized by prolonged hyperglycemia that leads to long-term health consequences. It is estimated that impaired healing of diabetic wounds affects approximately 25% of all patients with diabetes mellitus, often resulting in lower limb amputation, with subsequent high economic and psychosocial costs. The hyperglycemic environment promotes the formation of biofilms and makes diabetic wounds difficult to treat. In this review, we present updates regarding recent advances in our understanding of the pathophysiology of diabetic wounds focusing on impaired angiogenesis, neuropathy, sub-optimal chronic inflammatory response, barrier disruption, and subsequent polymicrobial infection, followed by current and future treatment strategies designed to tackle the various pathologies associated with diabetic wounds. Given the alarming increase in the prevalence of diabetes, and subsequently diabetic wounds, it is imperative that future treatment strategies target multiple causes of impaired healing in diabetic wounds.

Advances in pharmacotherapy for diabetic foot osteomyelitis

Introduction: The diagnosis of diabetic foot osteomyelitis (DFO) is usually clinical. Its severity is related to the location and depth of the lesion, and the presence of necrosis or gangrene. The aetiology of diabetic foot osteomyelitis (DFO) is usually polymicrobial, and DFO is often associated with chronic or recurring ulceration.Areas covered: We built on the  International Working Group on the Diabetic Foot (IWGDF) guidelines on the management of diabetic foot infection, providing an outline of the current and new concepts in pharmacotherapy in DFO. We assess future strategies in both medical, surgical and combination management of DFO.Expert opinion: Surgical removal of infected bone is considered as the standard treatment, but a medical approach of certain selected situations has now proven efficacy in selected patients. The combination of new modalities in local antibiotic delivery may provide better long-term solutions and more lasting remission and avoid the disadvantages of prolonged systemic antibiotics.