The effect of silicone injections in the diabetic foot on peak plantar pressure and plantar tissue thickness: a 2-year follow-up

Prevention of foot ulcers in persons with diabetes at risk of ulceration: A systematic review and meta-analysis

AIMS

Prevention of foot ulcers in persons with diabetes is important to help reduce the substantial burden on both individual and health resources. A comprehensive analysis of reported interventions is needed to better inform healthcare professionals about effective prevention. The aim of this systematic review and meta-analysis is to assess the effectiveness of interventions to prevent foot ulcers in persons with diabetes who are at risk thereof.

MATERIALS AND METHODS

We searched the available scientific literature in PubMed, EMBASE, CINAHL, Cochrane databases and trial registries for original research studies on preventative interventions. Both controlled and non-controlled studies were eligible for selection. Two independent reviewers assessed risk of bias of controlled studies and extracted data. A meta-analysis (using Mantel-Haenszel's statistical method and random effect models) was done when >1 RCT was available that met our criteria. Evidence statements, including the certainty of evidence, were formulated according to GRADE.

RESULTS

From the 19,349 records screened, 40 controlled studies (of which 33 were Randomised Controlled Trials [RCTs]) and 103 non-controlled studies were included. We found moderate certainty evidence that temperature monitoring (5 RCTs; risk ratio [RR]: 0.51; 95% CI: 0.31-0.84) and pressure-optimised therapeutic footwear or insoles (2 RCTs; RR: 0.62; 95% CI: 0.26-1.47) likely reduce the risk of plantar foot ulcer recurrence in people with diabetes at high risk. Further, we found low certainty evidence that structured education (5 RCTs; RR: 0.66; 95% CI: 0.37-1.19), therapeutic footwear (3 RCTs; RR: 0.53; 95% CI: 0.24-1.17), flexor tenotomy (1 RCT, 7 non-controlled studies, no meta-analysis), and integrated care (3 RCTs; RR: 0.78; 95% CI: 0.58-1.06) may reduce the risk of foot ulceration in people with diabetes at risk for foot ulceration.

CONCLUSIONS

Various interventions for persons with diabetes at risk for foot ulceration with evidence of effectiveness are available, including temperature monitoring (pressure-optimised) therapeutic footwear, structured education, flexor tenotomy, and integrated foot care. With hardly any new intervention studies published in recent years, more effort to produce high-quality RCTs is urgently needed to further improve the evidence base. This is especially relevant for educational and psychological interventions, for integrated care approaches for persons at high risk of ulceration, and for interventions specifically targeting persons at low-to-moderate risk of ulceration.

A Step in the Right Direction: A Prospective Randomized, Controlled Crossover Trial of Autologous Fat Grafting for Rejuvenation of the Heel

BACKGROUND

The shock-absorbing soft tissues of the heel are composed of dermis and specialized fat pads. Heel fat pad atrophy is common and can be painful and debilitating. In our previous work, autologous fat grafting was effective for treating pain from forefoot fat pad atrophy.

OBJECTIVES

The authors hypothesized that autologous fat grafting to the heel would relieve pain and improve function in patients with heel fat pad atrophy.

METHODS

Patients with heel fat pad atrophy and associated pain were recruited and randomized into 2 groups. Group 1 received autologous fat grafting on enrollment and was followed for 2 years. Group 2 received offloading and activity modification for 1 year, then crossed over, underwent autologous fat grafting, and was followed for 1 year afterward. Outcome measures included ultrasound-measured fat pad and dermal thickness; pedobarograph-measured foot pressures and forces; and patient-reported outcomes as measured by the Manchester Foot Pain and Disability Index.

RESULTS

Thirteen patients met the inclusion criteria and completed the study. Seven (12 affected feet) were randomized into Group 1; and 6 (9 affected feet) were randomized into Group 2. The average age was 55 years and BMI was 30.5 kg/m2. Demographics did not significantly differ between groups. Heel fat pad thickness increased after autologous fat grafting but returned to baseline at 6 months. However, autologous fat grafting increased dermal thickness significantly and also increased fat pad thickness under a compressive load compared with controls at 6 and 12 months. Foot pain, function, and appearance were also significantly improved compared with controls at 6 and 12 months.

CONCLUSIONS

Autologous fat grafting improved patient-reported foot pain, function, and appearance and may rejuvenate local soft tissues in patients with heel fat pad atrophy.

LEVEL OF EVIDENCE: 3

[Pattern analysis of inflammatory skin diseases according to A. B. Ackerman-always up to date]

The exact microscopic diagnosis of inflammatory skin diseases requires the linking of histopathological findings with clinical features. This is not easy when skin biopsies are rarely assessed and the terminology of dermatopathology and dermatology is itself unfamiliar.The infiltrates of almost all inflammatory skin diseases tend to show eight specific patterns in high magnification. By further classifying according to architectural and cytological features, a specific diagnosis can be made in most cases. At the same time, clinically suspected diagnoses are simply excluded or greatly reduced in number. This procedure, starting with the overview magnification and the recognition of clearly defined histomorphological features, corresponds to an algorithm.Another algorithmic approach uses histomorphological changes under high magnification. Here, "nonspecific" findings are added to the pattern analysis as a diagnostic vehicle.Occasionally, inflammatory skin diseases cannot be assessed conclusively with current modern methods. Such pathology reports should be written descriptively and possible differential diagnoses should be mentioned as notes. The report should be written in a language understandable to the clinician.Artificial intelligence, with its ability to transform and integrate extensive clinical as well as image data, will play an important role in the future of decision making, diagnosing, and personalizing medicine. In the field of pathology, it could be seen as a second opinion. It is important that physicians always contribute their opinion where important algorithmic decisions are made, such as in algorithm design, data quality, interpretation, action, and feedback.

Volumetric Analysis in Autologous Fat Grafting to the Foot

BACKGROUND

Pedal fat grafting is a safe, minimally invasive approach to treat pedal fat pad atrophy. Prior randomized controlled trials demonstrate that the fat as measured directly under the metatarsal heads disappears between 2 and 6 months after fat grafting, despite patients having relief for 2 years. The authors aim to use magnetic resonance imaging to further assess three-dimensional volume of fat in the foot after autologous fat grafting to help explain the mechanism for improved pain.

METHODS

A prospective study was performed using magnetic resonance imaging before and at 6 months after pedal fat grafting to assess changes in the three-dimensional morphology of the fat.

RESULTS

Seventeen patients (six men and 11 women) underwent injections with a mean volume of 5.8 cc per foot. At 6 months, patients demonstrated increased tissue thickness (p = 0.008) and volume (p = 0.04). Improvements were seen in pain (p < 0.05) and activity (p < 0.05). Foot pressures and forces were significantly decreased and positively correlated with increased fat pad volume (p < 0.05).

CONCLUSIONS

Pedal fat grafting significantly increases metatarsal fat pad volume. The distribution of the fat may contribute to lasting clinical relief in these patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Fat Grafting for Pedal Fat Pad Atrophy in a 2-Year, Prospective, Randomized, Crossover, Single-Center Clinical Trial

BACKGROUND

By age 60, 30 percent of Americans suffer from fat pad atrophy of the foot. Forefoot fat pad atrophy results from long-term aggressive activity, genetically dictated foot type, multiple forefoot steroid injections, surgery, and foot trauma.

METHODS

The authors present data from a 2-year, prospective, randomized crossover study performed to assess pain and disability indexes, fat pad thickness, forces, and pressures of stance and gait. Group 1 underwent fat grafting with 2 years of follow-up, and group 2 underwent conservative management for 1 year, then underwent fat grafting with 1 year of follow-up.

RESULTS

Eighteen subjects (14 women and four men) constituted group 1. Thirteen subjects (nine women and four men) constituted group 2. Group 1 reported the worst pain at baseline and group 2 experienced the worst pain at 6- and 12-month standard-of-care visits; pain for both groups improved immediately following fat grafting and lasted through study follow-up (p < 0.05). Group 1 demonstrated functional improvements at 12, 18, and 24 months postoperatively (p < 0.05), whereas group 2 demonstrated the highest function at 12 months postoperatively (p < 0.05). Pedal fat pad thickness of subjects in group 1 increased postoperatively and returned to baseline thickness at 2 months postoperatively; subjects in group 2 experienced return to baseline thickness at 6 months postoperatively (p < 0.01). Forces and pressures of stance and gait increased over the 2 years of follow-up for group 1 (p < 0.05).

CONCLUSION

Pedal fat grafting provides long-lasting improvements in pain and function, and prevents against worsening from conservative management.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

The Influence of Fat Grafting on Skin Quality in Cosmetic Foot Grafting: A Randomized, Cross-Over Clinical Trial

BACKGROUND

Pedal fat grafting is a cosmetic procedure to treat the functional and aesthetic sequelae of pedal fat pad atrophy. Fat grafting has been found to mitigate these symptoms, but the exact mechanism is unknown.

OBJECTIVES

The authors hypothesized that pedal fat grafting may improve skin quality, accounting for prolonged symptomatic improvement despite loss of grafted fat.

METHODS

Patients with pedal atrophy were enrolled in a randomized crossover clinical trial. Group 1 underwent fat grafting upon enrollment with 2-year follow-up. Group 2 was managed conservatively for 1 year then placed into the fat grafting group with 1-year follow-up. Patients underwent pedal ultrasounds to determine thicknesses of the fat pad and dermis, and photographs were taken to assess skin quality.

RESULTS

Three men and 20 women with an average age of 63 ± 6 years and an average BMI of 26.0 ± 4.6 kg/m2 were enrolled in the study. Twenty-six feet were injected in Group 1 and 17 were injected in Group 2. Group 1 dermal thickness increased at 6 months post-injection (P < 0.05). This increase persisted through 24 months. Group 2 dermal thickness decreased prior to injection (P < 0.05) but returned to baseline after injection and through 12-month follow-up (P < 0.05). Fat pad thickness returned to baseline by study completion in both groups (P < 0.05).

CONCLUSIONS

Pedal fat grafting yielded a significant, sustained increase in dermal thickness, though grafted fat was not retained. Fat grafting may improve skin quality, which could contribute to improved clinical outcomes despite loss of grafted fat.

LEVEL OF EVIDENCE: 2

Comparison of Pedal Soft Tissue Thickness Between Those With and Without Diabetes

Ulceration is a serious consequence of diabetes that can lead to disability in patients with diabetes. One of the risk factors for ulceration is high foot pressure. The thickness of the pedal soft tissue is important because it has a cushioning effect. Soft tissue atrophy causes elevation in the plantar pressure, which, in turn, causes ischemia. Therefore, we investigated the severity of pedal soft tissue atrophy caused by diabetes and aging. From February 2009 to February 2016, we examined the feet of 261 patients treated in our hospital using magnetic resonance imaging. We divided the patients enrolled in the study into 2 groups. The first group included 52 patients with diabetes but without peripheral arterial disease and the second group included 47 patients without diabetes. We measured the vertical distances under all patients' metatarsal heads using T1-weighted magnetic resonance imaging and measured the pedal soft tissue thickness using the PACS workstation (m-view). We compared the soft tissue thicknesses of the 2 groups and performed statistical analyses of the relationships between these data and other parameters using 2-way analysis of variance. The soft tissue under the first to fourth metatarsal heads was thinner in the diabetic patients than in the nondiabetic patients (first metatarsal, 6.4 versus 8.69; second metatarsal, 8.85 versus 10.64; third metatarsal, 8.15 versus 9.21; fourth metatarsal, 7.38 versus 8.54; p < .05). Aging had no effect on pedal soft tissue atrophy in either group. In conclusion, our study confirmed that diabetic patients experience more severe plantar soft tissue atrophy than nondiabetic patients. We have developed a standard procedure to enable the prediction of pedal soft tissue atrophy severity in diabetic patients.

Autologous Fat Grafting for Pedal Fat Pad Atrophy: A Prospective Randomized Clinical Trial

BACKGROUND

Pedal fat pad atrophy is associated with pain, decreased tissue thickness, and increased foot pressures. To date, no objective studies investigating the use of fat grafting to the forefoot have been performed. The authors hypothesize that pedal fat grafting can reduce pain, increase tissue thickness, and decrease pedal pressures.

METHODS

A prospective randomized study was performed to assess tissue thickness, pain, and foot pressures. Group 1 underwent fat grafting immediately with 1-year follow-up, and group 2 underwent conservative management for 1 year.

RESULTS

Thirteen patients (two men and 11 women) constituted group 1 and 12 patients (four men and eight women) constituted group 2. Ten patients in group 1 underwent bilateral injections with a mean volume of 4.8 cc per foot. Mean follow-up time was 11.1 ± 5.4 months for group 1 and 13.8 ± 4.2 months for group 2. At 1 year, group 1 demonstrated improved foot function (p = 0.022), pain (p = 0.022), and work/leisure activities (p = 0.021). Group 1 had no change in tissue thickness, whereas in group 2, the right third metatarsal tissue thickness decreased significantly (p = 0.036). Foot pressures in group 1 did not improve; however, group 2 had a significant increase in left foot pressure (p = 0.011). When comparing the groups at 1 year, group 2 had significantly higher foot pressures and forces than group 1 (p < 0.05).

CONCLUSIONS

Pedal fat grafting significantly improves pain and disability outcomes, and prevents against worsening foot pressures. Future analysis will reveal whether fat grafting has lasting efficacy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Review of the Biomechanics of the Diabetic Foot

In general, diabetic foot ulcers result from abnormal mechanical loading of the foot, such as repetitive moderate pressure applied to the plantar aspect of the foot while walking. Diabetic peripheral neuropathy causes changes in foot structure, affecting foot function and subsequently leading to increased plantar foot pressure, which is a predictive risk factor for the development of diabetic foot ulceration. Prevention of diabetic foot ulceration is possible by early identification of the insensitive foot, therefore a foot “at risk,” and by protecting the foot from abnormal biomechanical loading. Abnormal foot pressures can be reduced using several different approaches, including callus debridement, prescription of special footwear, injection of liquid silicone, Achilles tendon lengthening, and so forth. Off-loading of the diabetic wound is a key factor in successful wound healing, as it is associated with reduced inflammatory and accelerated repair processes. Pressure relief can be achieved using various off-loading modalities including accommodative dressing, walking splints, ankle-foot orthosis, total contact cast, and removable and irremovable cast walkers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The role of surgical off-loading to prevent recurrent ulcerations

Foot ulcerations in patients with diabetes are common. Most ulcers heal with conservative treatment, but recurrence is common. The pathway of ulcer development includes neuropathy, deformity, and trauma. The first attempt to avoid recurrence is by the use of shoes and insoles. When shoes and insoles fail, surgical correction of deformity leading to the ulcer can be attempted. This article reviews the most common procedures performed to heal ulcers or avoid recurrence.

Preventing the first or recurrent ulcers

Prevention is overlooked and underused, even in very high-risk patients. Prevention is best achieved within a multispecialty group of providers that have a common objective. Ideally, the team approach should include educators; physical therapists; nurses; internist; pedorthists; and vascular, orthopedic, and podiatric surgeons. The basic elements involve education, foot examination, risk classification, therapeutic shoes and insoles, and regular foot care. High-risk patients need additional assessment for vascular disease and intensive disease management, and corrective vascular and foot surgery when necessary. Basic interventions can reduce the incidence of foot ulcers by more than 50%.

The value of reporting pressure-time integral data in addition to peak pressure data in studies on the diabetic foot: a systematic review

BACKGROUND

In plantar pressure studies on the diabetic foot, pressure-time integral data is often analyzed and reported next to peak pressure data, mostly because of its assumed additional value. The aim was to assess this additional value by systematically reviewing the relevant literature.

METHODS

The MEDLINE database was searched for original articles that report both pressure-time integral and peak pressure data measured in the diabetic foot. Eligible articles were assessed according to differences in reported results between both parameters, the quality of discussion and specific conclusions drawn on pressure-time integral data, and the added value of the pressure-time integral data.

FINDINGS

All 35 eligible papers described studies on gait. Differences in reported results between parameters were found to be clear, minimal, or absent in 15, 8, and 12 papers, respectively. In 15 papers, the pressure-time integral results were discussed with respect to the peak pressure results, but in only 5 papers the explanation given for reported differences was considered meaningful. Specific conclusions were drawn in 11 papers. Some added value was found in 10 papers, but in all papers one or more limitations to this value applied.

INTERPRETATION

The study findings suggest that the added value of reporting pressure-time integral data is limited. Unless clear benefit can be shown such, as that ulceration can be better predicted using pressure-time integral than using peak pressure data, the reporting of pressure-time integral data seems redundant to express the plantar loading in the diabetic foot.

Neuropathic diabetic foot ulcers - evidence-to-practice

Foot ulcers and their attendant complications are disquietingly high in people with diabetes, a majority of whom have underlying neuropathy. This review examines the evidence base underpinning the prevention and management of neuropathic diabetic foot ulcers in order to inform best clinical practice. Since it may be impractical to ask patients not to weight-bear at all, relief of pressure through the use of offloading casting devices remains the mainstay for management of neuropathic ulcers, whilst provision of appropriate footwear is essential in ulcer prevention. Simple non-surgical debridement and application of hydrogels are both effective in preparing the wound bed for healthy granulation and therefore enhancing healing. Initial empirical antibiotic therapy for infected ulcers should cover the most common bacterial flora. There is limited evidence supporting the use of adjunctive therapies such as hyperbaric oxygen and cytokines or growth factors. In selected cases, recombinant human platelet-derived growth factor has been shown to enhance healing; however, its widespread use cannot be advised due to the availability of more cost-effective approaches. While patient education may be beneficial, the evidence base remains thin and conflicting. In conclusion, best management of foot ulcers is achieved by what is taken out of the foot (pressure, callus, infection, and slough) rather than what is put on the foot (adjuvant treatment).

Comparison of vacuum-assisted closure device and conservative treatment for fasciotomy wound healing in ischaemia-reperfusion syndrome: preliminary results

Ischaemia-reperfusion syndrome (IRS) is a condition that may require early fasciotomy. In the past, fasciotomies ultimately required prolonged hospitalisation. Vacuum-assisted closure (VAC) therapy system is an innovative method which promotes wound healing by reducing wound oedema, increasing microcirculation, and stimulation of granulation tissue. The aim of this retrospective study was to compare the VAC treatment with the conservative treatment of the fasciotomy wound until definitive surgical closure. The researchers retrospectively identified 15 patients, 3 females and 12 males, with a mean age of 69 years, who underwent a fasciotomy between January 2003 and December 2009 at the University Hospital of Geneva. All of the fasciotomies performed on the patients were on account of IRS. Seven patients were subjected to wound treatment using the VAC-system device and eight patients underwent treatment through the usual conservative method. The data were analysed by comparing the operative wound size, length of time for wound closure and duration of hospital stay in both groups. The number of days after fasciotomy until surgical wound closure in the VAC-system group (n = 7) ranged from 8 to 13 days with a mean of 11 days. The wound size at the day of closure was decreased in length by a mean of 58% (range 29-67%) and in diameter by a mean of 56% (range 33-75%). The duration of hospital stay for this group ranged from 12 to 18 days with a mean of 14 days. No signs of infections were observed and no re-operation was required after first closure. In the conservative group (n = 8), the time to wound closure ranged between 12 and 20 days with a mean of 15 days. The wound size was decreased in length by a mean of 40% (range 32-53%) and in diameter by a mean 46% (range 30-70%). The mean duration of hospital stay was 18·5 days. Three of the patients in the conservative treatment group manifested wound infection during the course of the treatment. VAC device could be a new standard for treatment of fasciotomy wound. VAC therapy is a recent innovation and becoming more and more a necessary complementary therapy to hasten wound healing. In our preliminary study, the VAC-system device showed significantly reduction of the wound size, decreased tissue oedema, duration of hospital days and improvement of granulation tissue.

Off-loading the diabetic foot for ulcer prevention and healing

Retrospective and prospective studies have shown that elevated plantar pressure is a causative factor in the development of many plantar ulcers in diabetic patients and that ulceration is often a precursor of lower-extremity amputation. Herein, we review the evidence that relieving areas of elevated plantar pressure (off-loading) can prevent and heal plantar ulceration.There is no consensus in the literature concerning the role of off-loading through footwear in the primary or secondary prevention of ulcers. This is likely due to the diversity of intervention and control conditions tested, the lack of information about off-loading efficacy of the footwear used, and the absence of a target pressure threshold for off-loading. Uncomplicated plantar ulcers should heal in 6 to 8 weeks with adequate off-loading. Total-contact casts and other nonremovable devices are most effective because they eliminate the problem of nonadherence to recommendations for using a removable device. Conventional or standard therapeutic footwear is not effective in ulcer healing. Recent US and European surveys show that there is a large discrepancy between guidelines and clinical practice in off-loading diabetic foot ulcers. Many clinics continue to use methods that are known to be ineffective or that have not been proved to be effective while ignoring methods that have demonstrated efficacy.A variety of strategies are proposed to address this situation, notably the adoption and implementation of recently established international guidelines, which are evidence based and specific, by professional societies in the United States and Europe. Such an approach would improve the often poor current expectations for healing diabetic plantar ulcers.

Off-loading the diabetic foot for ulcer prevention and healing

BACKGROUND

Retrospective and prospective studies have shown that elevated plantar pressure is a causative factor in the development of many plantar ulcers in diabetic patients and that ulceration is often a precursor of lower extremity amputation. In this article, we review the evidence that relieving areas of elevated plantar pressure (off-loading) can prevent and heal plantar ulceration.

RESULTS

There is no consensus in the literature concerning the role of off-loading through footwear in primary or secondary prevention of ulcers. This is likely due to the wide diversity of intervention and control conditions tested, the lack of information about off-loading efficacy of the footwear used, and the absence of a target pressure threshold for off-loading. Uncomplicated plantar ulcers should heal in 6 to 8 weeks with adequate off-loading. The total contact cast and other nonremovable devices are most effective because they eliminate the problem of nonadherence to recommendations for using a removable device. Conventional or standard therapeutic footwear is not effective in ulcer healing. Recent United States and European surveys show a large discrepancy between guidelines and clinical practice in off-loading diabetic foot ulcers. Many clinics continue to use methods that are known to be ineffective or have not been proven effective, while ignoring methods that have been demonstrated to be efficacious.

CONCLUSIONS

A number of strategies are proposed to address this situation, notably the adoption and implementation of recently established international guidelines, which are evidence-based and specific, by professional societies in the United States and Europe. Such an approach would change the often poor current expectations for healing diabetic plantar ulcers.

Liquid silicone to mitigate plantar pedal pressure: a literature review

Disruption of the body's plantar fat pad can occur as a result of one of three mechanisms: simple fat pad atrophy associated with age-related degeneration, steroid use, or collagen vascular disease. Actual or relative displacement in to the underlying osseous prominences may be seen in association with structural deformity of the foot. Disease states such as diabetes may alter the normal structural integrity of soft tissues through nonenzymatic glycation leading to increased stiffness and thus reduced attenuating capacity. Fat pad atrophy, regardless of the cause, is often associated with substantial emotional, physical, productivity, and financial losses. In situations where the patient is sensate, the resultant skin on bone situation is extremely painful, especially when walking.

The characterization and optimization of injectable silicone resin particles in conjunction with dermal fibroblasts and growth factors: an in vitro study

Minimally invasive subdermal injection of liquid silicone has been used clinically to augment the soft tissue of the foot to mitigate high pressures that cause diabetic foot ulcers. However, implant migration has been a clinical issue. The objective of this study was to assess the effects of three specific concentrations of silicone resin particles (12 mum average diameter) in conjunction with either platelet-derived growth factor (PDGF-BB) or basic fibroblast growth factor (bFGF) on fibroblast cell proliferation, collagen synthesis, cell morphology, and migration through in vitro assays and a monolayer scratch wound model. PDGF and bFGF enhanced the proliferation of fibroblasts 5.7-fold and fivefold, respectively, while the addition of silicone particles had no significant effect on proliferation. Collagen production was increased approximately twofold with the addition of bFGF and the medium concentration of particles over bFGF without particles and the PDGF groups. The addition of silicone particles had no significant effect on collagen production compared with control groups without particles. Fibroblast migration was enhanced by the addition of both PDGF and bFGF compared to controls, although slower scratch wound closure rates were observed in the presence of particles compared to controls without particles. Cell morphology suggested that particles induced cellular aggregation encircling silicone particles postwounding as well as migration into the wound area. These results suggest that silicone particles in combination with a growth factor might enhance fibroblast aggregation and implant stability, and could promote connective tissue ingrowth and implant encapsulation in the soft tissue of the diabetic foot.

Effect of growth factors in combination with injectable silicone resin particles on the biological activity of dermal fibroblasts: a preliminary in vitro study

Injections of silicone fluid have been clinically evaluated to treat and prevent foot ulcers due to diminished plantar fat-pad in neuropathic diabetics. The objective of this study was to determine preliminary in vitro effects of an injectable form of silicone resin particles in combination with growth factors to determine the suitability of this potential therapy for prevention of diabetic foot ulcers. Basic fibroblast growth factor (bFGF), epidermal growth factor (EGF) and platelet-derived growth factor (PDGF-BB) were added to monolayer culture along with silicone resin particles (12 microm average diameter). Growth factors were also combined as follows: bFGF+PDGF-BB, EGF+PDGF-BB, and bFGF+EGF. Growth factors alone and in combination increased fibroblast proliferation, but the presence of particles did not significantly affect cellular proliferation. The addition of particles significantly increased fibronectin production 117% in the control group and 151% in the PDGF only group. Collagen production was increased with exposure to EGF and growth factor combinations, but the presence of particles did not lead to any significant differences, except an 81% increase in the bFGF group. These preliminary results suggest that a combination of PDGF and bFGF may be effective in stimulating proliferation and matrix production around injectable silicone resin particles to generate a fibrous tissue pad to alleviate the abnormal distribution of high pressures that contribute to diabetic foot ulcer formation.

Augmentation of atrophic plantar soft tissue with an acellular dermal allograft: a series review

Treatment of plantar fat pad migration and atrophy has caused concern for decades. Patients can present with pain, callus formation, or ulceration. The purpose of this article is to review the results of a consecutive series of patients treated for fat pad atrophy of the plantar foot, using a minimally invasive implantation of an acellular human dermal allograft as a tissue augmentation. This material was chosen for the fat pad supplementation because of previous reports of success in tendon and ligament augmentation, wound healing, and interpositional arthroplasty.

Clinical outcome of diabetic foot ulcers treated with negative pressure wound therapy and the transition from acute care to home care

Diabetic foot ulcers affect millions of people in the United States of America and impose tremendous medical, psychosocial and financial loss or burden. Negative pressure wound therapy (NPWT) is generally well tolerated and appears to stimulate a robust granulation tissue response compared with other wound healing modalities. This device may be a cost-effective adjunctive wound healing therapy. This literature review will focus on the clinical outcome of diabetic foot ulcers treated with NPWT, its implication in the transition from acute care to home care, factors that might influence clinical outcomes in home care as well as quality-of-life aspects in these patients. Patient care for diabetic foot ulceration is complex and necessitates multiprofessional collaboration to provide comprehensive wound care. It is clear that when we strive for limb preservation in this most high-risk population, it is important to have an available versatile, efficacious wound healing modality. There is a need for an easy transition from acute care to home care. Resources need to be combined in a collaborative and synergistic fashion to allow patient to perform many daily living activities while receiving the potential benefits of an advanced wound healing modality.

The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review

BACKGROUND

Footwear and offloading techniques are commonly used in clinical practice for the prevention and treatment of foot ulcers in diabetes, but the evidence base to support this use is not well known. The goal of this review was to systematically assess the literature and to determine the available evidence on the use of footwear and offloading interventions for ulcer prevention, ulcer treatment, and plantar pressure reduction in the diabetic foot.

METHODS

A search was made for reports on the effectiveness of footwear and offloading interventions in preventing or healing foot ulcers or reducing plantar foot pressure in diabetic patients published prior to May 2006. Both controlled and uncontrolled studies were included. Assessment of the methodological quality of studies and data extraction was independently performed by two reviewers. Interventions were assigned into four subcategories: casting, footwear, surgical offloading and other offloading techniques.

RESULTS

Of 1651 articles identified in the baseline search, 21 controlled studies were selected for grading following full text review. Another 108 uncontrolled and cross-sectional studies were examined. The evidence to support the use of footwear and surgical interventions for the prevention of ulceration is meagre. Evidence was found to support the use of total contact casts and other non-removable modalities for treatment of neuropathic plantar ulcers. More studies are needed to support the use of surgical offloading techniques for ulcer healing. Plantar pressure reduction can be achieved by several modalities including casts, walkers, and therapeutic footwear, but the diversity in methods and materials used limits the comparison of study results.

CONCLUSIONS

This systematic review provides support for the use of non-removable devices for healing plantar foot ulcers. Furthermore, more high-quality studies are urgently needed to confirm the promising effects found in both controlled and uncontrolled studies of footwear and offloading interventions designed to prevent ulcers, heal ulcers, or reduce plantar pressure.

Diabetic Foot Disease

OBJECTIVE

To review the spectrum of foot problems in patients with diabetes and the underlying etiologic factors.

METHODS

In this review, the term "diabetic foot disease" (DFD) will be used (previously referred to as simply "diabetic foot"). The relevant anatomy of the foot is discussed, the clinical evaluation and severity of DFD are outlined, and the role of both systemic control and local measures in the management of DFD is addressed.

RESULTS

DFD is linked with a wide variety of etiologic associations, pathologic forms, and clinical severity. The causes of DFD include such factors as diabetic neuropathy, vascular insufficiency, and the presence of underlying bone deformity. The pathologic forms range from superficial skin lesions, soft tissue infections, joint swellings, and deformities to frank necrosis and gangrene. The clinical severity ranges from mild, self-resolving disease to fulminant, rapidly progressive disease that usually eventuates in amputation. The heterogeneity of patients whose illness is grouped collectively under the diagnosis of DFD has contributed to the persisting confusion and controversy regarding the optimal classification system for diabetes-related foot problems and their appropriate management.

CONCLUSION

Optimal management of DFD involves a multimodality approach directed at regular foot care, blood glucose control, and early recognition of foot problems. Appropriate surgical management, administration of systemic antibiotics, and off-loading techniques are necessary to prevent the progression of DFD.

The diabetic foot: from art to science. The 18th Camillo Golgi lecture

Diabetic foot ulceration represents a major medical, social and economic problem all over the world. While more than 5% of diabetic patients have a history of foot ulceration, the cumulative lifetime incidence may be as high as 15%. Ethnic differences exist in both ulcer and amputation incidences, with both being less common in patients of Indian subcontinent origin living in the UK. Foot ulceration results from the interaction of several contributory factors, the most important of which is neuropathy. With respect to the management of acute Charcot neuroarthropathy in diabetes, recent studies suggest that bisphosphonates reduce disease activity as judged not only by differences in skin temperature, but also by assessing markers of bone turnover. The use of the total-contact cast is demonstrated in the treatment of acute Charcot feet and of plantar neuropathic ulcers. Histological evidence suggests that pressure relief results in chronic foot ulcers changing their morphological appearance by displaying some features of an acute wound. Thus, repetitive stresses on the insensate foot appear to play a major role in maintaining ulcer chronicity. It is hoped that increasing research activity in foot disease will ultimately result in fewer ulcers and less amputation in diabetes.