It's not what you put on, but what you take off: techniques for debriding and off-loading the diabetic foot wound

Early identification of delayed wound healing in complex diabetic foot ulcers treated with a dermal regeneration template: a novel clinical target and its risk factors

BACKGROUND

The dermal regeneration template (DRT), a tissue-engineered skin substitute composing a permanent dermal matrix and an upper temporary silicone layer that serves as the epidermis, has demonstrated efficacy in treating uncomplicated diabetic foot ulcers (DFUs). Our institution has obtained good outcomes with DRT in patients with more complicated DFUs. Because of its chronicity, the authors are working to identify a clinical target that anticipates delayed healing early in the treatment in addition to determining the risk factors linked to this endpoint to increase prevention.

MATERIALS AND METHODS

This retrospective single-center study analyzed patients with DFUs who underwent wound reconstruction using DRT between 2016 and 2021. The patients were categorized into poor or good graft-take groups based on their DRT status on the 21st day after the application. Their relationship with complete healing (CH) rate at day 180 was analyzed. Variables were collected for risk factors for poor graft take at day 21. Independent risk factors were identified after multivariable analysis. The causes of poor graft take were also reported.

RESULTS

This study examined 80 patients (38 and 42 patients in the poor and good graft-take groups, respectively). On day 180, the CH rate was 86.3% overall, but the poor graft-take group had a significantly lower CH rate (76.3 vs. 95.2%, P =0.021) than the good graft-take group. Our analysis identified four independent risk factors: transcutaneous oxygen pressure less than 30 mmHg (odds ratio, 154.14), off-loading device usage (0.03), diabetic neuropathy (6.51), and toe wound (0.20). The most frequent cause of poor graft take was infection (44.7%), followed by vascular compromise (21.1%) and hematoma (15.8%).

CONCLUSION

Our study introduces the novel concept of poor graft take at day 21 associated with delayed wound healing. Four independent risk factors were identified, which allows physicians to arrange interventions to mitigate their effects or select patients more precisely. DRT represents a viable alternative to address DFUs, even in complicated wounds. A subsequent split-thickness skin graft is not always necessary to achieve CH.

Stem Cell-Based Therapy: A Promising Treatment for Diabetic Foot Ulcer

Diabetic foot ulcer (DFU) is a severe complication of diabetes and a challenging medical condition. Conventional treatments for DFU have not been effective enough to reduce the amputation rates, which urges the need for additional treatment. Stem cell-based therapy for DFU has been investigated over the past years. Its therapeutic effect is through promoting angiogenesis, secreting paracrine factors, stimulating vascular differentiation, suppressing inflammation, improving collagen deposition, and immunomodulation. It is controversial which type and origin of stem cells, and which administration route would be the most optimal for therapy. We reviewed the different types and origins of stem cells and routes of administration used for the treatment of DFU in clinical and preclinical studies. Diabetes leads to the impairment of the stem cells in the diseased patients, which makes it less ideal to use autologous stem cells, and requires looking for a matching donor. Moreover, angioplasty could be complementary to stem cell therapy, and scaffolds have a positive impact on the healing process of DFU by stem cell-based therapy. In short, stem cell-based therapy is promising in the field of regenerative medicine, but more studies are still needed to determine the ideal type of stem cells required in therapy, their safety, proper dosing, and optimal administration route.

Pressure relieving interventions for the management of diabetes-related foot ulcers: a study from the Northern Territory of Australia

BACKGROUND

Offloading intervention is an important component in the management of diabetes-related foot ulcer (DFU). The NT population is unique with certain distinctive challenges. Potential advantages of and barriers to optimal offloading methods in our setting were investigated.

METHODS

Consecutive patients with DFU treated with offloading devices between 2003 and 2015 at the Multidisciplinary Foot Clinic (MDFC), Royal Darwin Hospital were included. The outcome measures were healing, amputation and discontinuation. Risk factors for offloading failure were studied.

RESULTS

Total contact cast (TCC) was the most common offloading used (n = 175). The other removable non-TCC devices used were therapeutic footwear (n = 74), CamWalker (n = 35), and orthotic devices (n = 43). The overall healing rate was 88.7%. Healing rates were higher (93.2% versus 83.5%, P < 0.05) and amputation rates were lower (4.0% versus 7.3%, P = 0.026) in the TCC group than in the removable non-TCC group. The mean duration of offloading was longer in the TCC group (3.6 ± 1.5 versus. 3.2 ± 1.5 months, P = 0.008). Wagner grade ≥ 2 and removable non-TCC devices were significant risk factors for offloading failure.

CONCLUSION

Patients treated with TCC had higher healing rates than those treated with removable non-TCC devices. The duration of offloading was longer than reported in other studies. Higher Wagner grade and removable non-TCC devices were risk factors for offloading failure. Non-removable offloading devices are the first choice in diabetes-related neuropathic ulcers.

Teaching Wound Care to Family Caregivers: An overview of methods to use to promote wound healing

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. The articles in this new installment of the series provide simple and useful instructions that nurses should reinforce with family caregivers who perform wound care tasks. Each article also includes an informational tear sheet-Information for Family Caregivers-that contains links to instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

An exploration of the use of 3D printed foot models and simulated foot lesions to supplement scalpel skill training in undergraduate podiatry students: A multiple method study

BACKGROUND

Podiatrists regularly use scalpels in the management of foot pathologies, yet the teaching and learning of these skills can be challenging. The use of 3D printed foot models presents an opportunity for podiatry students to practice their scalpel skills in a relatively safe, controlled risk setting, potentially increasing confidence and reducing associated anxiety. This study evaluated the use of 3D printed foot models on podiatry students' anxiety and confidence levels and explored the fidelity of using 3D foot models as a teaching methodology.

MATERIALS AND METHODS

Multiple study designs were used. A repeated measure trial evaluated the effects of a 3D printed foot model on anxiety and confidence in two student groups: novice users in their second year of podiatry studies (n = 24), and more experienced fourth year students completing a workshop on ulcer management (n = 15). A randomised controlled trial compared the use of the 3D printed foot models (n = 12) to standard teaching methods (n = 15) on students' anxiety and confidence in second year students. Finally, a focus group was conducted (n = 5) to explore final year student's perceptions of the fidelity of the foot ulcer models in their studies.

RESULTS

The use of 3D printed foot models increased both novice and more experienced users' self-confidence and task self-efficacy; however, cognitive and somatic anxiety was only reduced in the experienced users. All changes were considered large effects. In comparison to standard teaching methods, the use of 3D printed foot models had similar decreases in anxiety and increases in confidence measures. Students also identified the use of 3D foot models for the learning of scalpel skills as 'authentic' and 'lifelike' and led to enhanced confidence prior to assessment of skills in more high-risk situations.

CONCLUSION

Podiatry undergraduate programs should consider using 3D printed foot models as a teaching method to improve students' confidence and reduce their anxiety when using scalpels, especially in instances where face-to-face teaching is not possible (e.g., pandemic related restrictions on face-to-face teaching).

A Meta-Analysis of the Outcomes of Resection Arthroplasty for Resistant Hallucal Diabetic Ulcers

The standard medical care (SC) of non-infected diabetic foot ulcers (DFUs) has been reported to yield varying rates of wound healing with high recurrence rate in non-infected wounds. Conservative surgery has been advanced as an alternative to SC in treating resistant non-complicated and complicated DFUs. Studies reporting resection arthroplasty (RA) of the first metatarsal head stated high healing rates with less recurrence. The aim of this meta-analysis is to quantitatively assess the efficacy of the RA procedure. Based on 9 included studies (3 case-control and 6 case-series) with 225 patients (244 feet, 244 hallucal plantar ulcers) and a mean follow-up period was of 22.8 ±13.3 months, the weighted estimates of comparative studies (RA vs. SC) were as follows: healing rate (100% vs. 79.9%, p = .0001), time to heal (3.3 ±0.28 vs. 8.4 ±1.5 weeks, p = .002), recurrence rate (5.7% vs. 25.4%, p = .001) and transfer rate (4.5% vs. 1.4%, p = .1). Similar values were found when analyzing case-series of non-infected and infected wounds treated with RA. Based on the available evidence, resection arthroplasty of the first ray is to be considered an effective conservative surgery in treating resistant or complicated hallucal neuropathic ulcers. Further prospective controlled trials are warranted to validate the review findings.

Molecular Biomarkers of Oxygen Therapy in Patients with Diabetic Foot Ulcers

Hyperbaric oxygen therapy (HBOT) and topical oxygen therapy (TOT) including continuous diffuse oxygen therapy (CDOT) are often utilized to enhance wound healing in patients with diabetic foot ulcerations. High pressure pure oxygen assists in the oxygenation of hypoxic wounds to increase perfusion. Although oxygen therapy provides wound healing benefits to some patients with diabetic foot ulcers, it is currently performed from clinical examination and imaging. Data suggest that oxygen therapy promotes wound healing via angiogenesis, the creation of new blood vessels. Molecular biomarkers relating to tissue inflammation, repair, and healing have been identified. Predictive biomarkers can be used to identify patients who will most likely benefit from this specialized treatment. In diabetic foot ulcerations, specifically, certain biomarkers have been linked to factors involving angiogenesis and inflammation, two crucial aspects of wound healing. In this review, the mechanism of how oxygen works in wound healing on a physiological basis, such as cell metabolism and growth factor signaling transduction is detailed. Additionally, observable clinical outcomes such as collagen formation, angiogenesis, respiratory burst and cell proliferation are described. The scientific evidence for the impact of oxygen on biomolecular pathways and its relationship to the outcomes in clinical research is discussed in this narrative review.

A Meta-Analysis of the Outcomes of Metatarsal Head Resection for the Treatment of Neuropathic Diabetic Foot Ulcers

Significance: Diabetic foot ulcers (DFUs) are associated with high morbidity, mortality, and health costs. Standard care (SC) associated with nonsurgical offloading is the mainstay treatment for DFUs, but it has high recurrence and infection rates. Metatarsal head resection (MHR) has been proposed as an effective surgical offloading technique for the treatment of plantar neuropathic DFUs, but with no evidence synthesis yet. Recent Advances: Based on PRISMA guidelines, a meta-analysis was conducted to assess the efficacy of MHR. Four electronic databases were searched for. Eleven studies met the inclusion criteria with a total of 477 patients (494 feet and 593 neuropathic forefoot ulcers). The studies included three retrospective comparative studies and eight case series. Critical Issues: Meta-analytical results of comparative studies on recent noninfected DFUs showed MHR having significantly better rates of healing, time to healing, ulcer recurrence, and infection than SC. Failure to heal, recurrence, and infection rates were 4 times higher in the SC group than in the MHR group, and the amputation rate was two times higher in the SC group than in the MHR group. The outcomes of the meta-analysis of case series on chronic and recalcitrant ulcers treated with MHR were similar. Future Directions: Considering the natural history of DFUs treated conservatively and the satisfactory outcomes with a significantly low complication rate of MHR, physicians should consider the use of MHR more often and include this technique in the early management of DFUs. Scope and Significance: DFU impose great public health burden around the globe. Standard of care using in-office debridement and topical agents is the usual mainstay of treatment. However, such conservative care is known to result in high rates of ulcer recurrence and complications. In this systematic review, we quantitatively investigate the outcomes of a surgical off-loading technique, the MHR in the treatment of chronic plantar neuropathic wounds. Translational Relevance: Many biochemical factors are implicated in the complex process of wound healing. In the case of diabetic neuropathic ulcers of the forefoot, additional mechanical factors induced by the presence of diabetic neuropathy lead to high pressure loads of the metatarsal heads on the plantar skin. With time, such chronic loads could favor ulcer formation. Removal of the causal mechanical factor could alleviate the pressure and allow wound healing. Clinical Relevance: Neuropathic plantar ulcers are difficult-to-heal wounds and chronicity is associated to frequent hospitalizations, higher rates of amputation, and mortality. Early removal of the indirect causal agent, the resection of the metatarsal head, after failure of a well-conducted conservative standard of care could be a needed solution for wound healing and consequently a potential for reducing complications and costs.

MRI nomenclature for musculoskeletal infection

The Society of Skeletal Radiology (SSR) Practice Guidelines and Technical Standards Committee identified musculoskeletal infection as a White Paper topic, and selected a Committee, tasked with developing a consensus on nomenclature for MRI of musculoskeletal infection outside the spine. The objective of the White Paper was to critically assess the literature and propose standardized terminology for imaging findings of infection on MRI, in order to improve both communication with clinical colleagues and patient care.A definition was proposed for each term; debate followed, and the committee reached consensus. Potential controversies were raised, with formulated recommendations. The committee arrived at consensus definitions for cellulitis, soft tissue abscess, and necrotizing infection, while discouraging the nonspecific term phlegmon. For bone infection, the term osteitis is not useful; the panel recommends using terms that describe the likelihood of osteomyelitis in cases where definitive signal changes are lacking. The work was presented virtually to SSR members, who had the opportunity for review and modification prior to submission for publication.

Telehealth-guided home-based maggot debridement therapy for chronic complex wounds: Peri- and post-pandemic potential

Patients with complex chronic lower extremity wounds require a great deal of interaction with outpatient and inpatient services. Paradoxically, these are the very patients that, because of their chronic comorbidities, are at greatest risk for COVID-related morbidity and mortality. Disinfected Phaenicia (Lucilia) sericata (Medical Maggots; Monarch Labs, Irvine, California) were applied in a standardised fashion by a home-health nurse with direct monitoring, guidance, and collaboration of the attending surgeon. A family member was able to change the outer dressing daily based on normal wound exudate. The inner maggot debridement therapy (MDT) dressing was changed at 2 days showing dramatic reduction in necrotic tissue, elimination of profound malodor, and no evidence of local or advancing infection. The entire initial telehealth-guided application took approximately 20 minutes. The first telehealth-guided MDT dressing change took 14 minutes. We used an artificial-intelligence-based algorithm to measure changes in wound characteristics. At day 0, 46% of the total surface area was covered in malodorous black, necrotic tissue. The first dressing change saw an elimination in assessed malodor with necrotic tissue constituting 14% of total surface area. The second dressing change at 5 days showed a greater than 99% reduction in necrotic tissue. This manuscript constitutes what we believe to be the first telehealth-guided MDT conducted during a resource-limited peri-pandemic period. We believe that MDT, which is an extension of efforts regularly performed in clinic and hospital, may have the potential to reduce resource usage while potentially improving care and quality of life for people with limb and life-threatening complications of diabetes and other chronic diseases.

Use of perfusional CBCT imaging for intraprocedural evaluation of endovascular treatment in patients with diabetic foot: a concept paper

Diabetes mellitus (DM) is one of the most common metabolic diseases worldwide; its global burden has increased rapidly over the past decade, enough to be considered a public health emergency in many countries. Diabetic foot disease and, particularly diabetic foot ulceration, is the major complication of DM: through a skin damage of the foot, with a loss of epithelial tissue, it can deepen to muscles and bones and lead to the amputation of the lower limbs. Peripheral arterial disease (PAD) in patients with diabetes, manifests like a diffuse macroangiopathic multi-segmental involvement of the lower limb vessels, also connected to a damage of collateral circulation; it may also display characteristic microaneurysms and tortuosity in distal arteries. As validation method, Bold-MRI is used. The diabetic foot should be handled with a multidisciplinary team approach, as its management requires systemic and localized treatments, pain control, monitoring of cardiovascular risk factors and other comorbidities. CBCT is an emerging medical imaging technique with the original feature of divergent radiation, forming a cone, in contrast with the spiral slicing of conventional CT, and has become increasingly important in treatment planning and diagnosis: from small anatomical areas, such as implantology, to the world of interventional radiology, with a wide range of applications: as guidance for biopsies or ablation treatments. The aim of this project is to evaluate the usefulness of perfusion CBCT imaging, obtained during endovascular revascularization, for intraprocedural evaluation of endovascular treatment in patients with diabetic foot. (www.actabiomedica.it).

What to put on (and what to take off) a wound: treating a chronic neuropathic ulcer with an autologous homologous skin construct, offloading and common sense

Closure of chronic lower extremity wounds is important for minimizing the risk of infection and amputation in a very high-risk population. Developments in tissue cultures and matrix therapies have shown promise in enhancing healing. The use of autologous homologous skin constructs in wound treatment may enable the regeneration of functional dermal structures. We present the case of a chronic medial heel ulcer that dehisced following intraoperative debridement, which was subsequently treated using a combination of an autologous homologous skin construct and total contact casting. This case emphasizes the importance of proper offloading for healing and preventing recurrence of lower extremity wounds.

Comparison of Collagen Granule Dressing Versus Conventional Dressing in Patients With Diabetic Foot Ulcer

Background. Diabetic foot ulcer (DFU) is a difficult, chronic wound with a significant long-term influence on the morbidity, mortality, and quality of life of patients. There is much information about the biochemical features of collagen and its function in wound healing. The aim of this study was to compare the results of DFU patients treated with and without collagen. Methods. A retrospective evaluation was made of the data of patients with DFU who underwent collagen treatment and physiological serum (PS) treatment. The patients were followed-up for a minimum of 12 weeks, and all complications, healing process, and wound characteristics were recorded. Results. Of the total 64 DFU patients included in the study, 30 were treated with PS and 34 with collagen. Complete closure was achieved in 17 (56.6%) of the PS group patients after 12 weeks of treatment. The rate was 25 (73.5%) in the collagen group. The mean duration of treatment was 9.2 weeks (range = 6-12 weeks) in the PS group and 8.08 weeks (range = 5-12 weeks) in the collagen group. The recovery time and recovery rates were determined to be better in the collagen group than in the PS group. Conclusion. A significant reduction in wound size was seen in the collagen group compared with the PS group. The results of this study demonstrated that collagen dressings are better than conventional dressings with regard to early granulation tissue and shorter hospital stay.

The Real-Life Outcome of VACOped Boot in the Management of Diabetic Foot Ulcers

The total contact cast (TCC) is considered the gold standard treatment to off-load diabetic foot ulcers (DFUs); however, the use of TCC can be limited due to various reasons such as underlying infections, ischemia, and patient's reluctance. Removable cast walkers are used in such cases, and the VACOped boot is one such device. The aim of this study was to analyze the results of the VACOped boot in the treatment of DFUs in real life. Case records of all patients with DFUs treated with a VACOped from 2011 to 2017 were reviewed retrospectively. Eighty-three episodes of ulcerations in 42 subjects were identified, of which 48 (57.8%) healed in a median duration of 17.5 (95% confidence interval = 15-33) weeks with the use of the VACOped and 35 (42.2%) discontinued its use. The median duration of healing with the VACOped of 17.5 weeks appears to be longer, but this cohort included patients with underlying infection and ischemia, which are often excluded in the clinical trials of off-loading. Our data show that the VACOped application is preferred by many patients and seems to be equally effective to other removable cast walkers.

Surgery Versus Nonsurgical Methods in Treating Neuropathic Plantar Forefoot Ulcers: A Meta-Analysis of Comparative Studies

The treatment of diabetic foot ulcers (DFUs) is usually based on local debridement, topical agents, and nonsurgical off-loading. When compared with nonsurgical methods, a number of articles reported better results with surgery. The aim of this meta-analysis was to collate quantitative evidence on the outcomes of surgery versus nonsurgical treatment (NST) of DFUs. Databases were searched from inception to September 2019. PRISMA guidelines were followed, and the Joanna Briggs Institute critical appraisal tools were used to appraise studies' quality. Nine studies were included totalizing 436 ulcers (216 treated with surgery and 220 DFUs with NST). The primary outcome was the healing rate. The secondary outcomes were time to heal, recurrence rate, transfer rate, infection rate, and amputation/revision surgery rate. The risk differences (RDs) between the healing rates following surgery and NST for infected and noninfected ulcers were 17% (95% confidence interval [CI] = 0.012-0.328, P = .03) and 19.2% (95% CI = 0.050-0.334, P = .008), respectively, in favor of surgery. The amputation/revision surgery rate was significantly better following surgery for both types of ulcers. Noninfected ulcers demonstrated significantly lesser time to heal, recurrence, and infection rates following surgery. This meta-analysis demonstrated that surgery was superior to NST in treating infected and noninfected neuropathic plantar wounds.

A Review of Wearable Sensor Systems to Monitor Plantar Loading in the Assessment of Diabetic Foot Ulcers

Diabetes is highly prevalent throughout the world and imposes a high economic cost on countries at all income levels. Foot ulceration is one devastating consequence of diabetes, which can lead to amputation and mortality. Clinical assessment of diabetic foot ulcer (DFU) is currently subjective and limited, impeding effective diagnosis, treatment and prevention. Studies have shown that pressure and shear stress at the plantar surface of the foot plays an important role in the development of DFUs. Quantification of these could provide an improved means of assessment of the risk of developing DFUs. However, commercially-available sensing technology can only measure plantar pressures, neglecting shear stresses and thus limiting their clinical utility. Research into new sensor systems which can measure both plantar pressure and shear stresses are thus critical. Our aim in this paper is to provide the reader with an overview of recent advances in plantar pressure and stress sensing and offer insights into future needs in this critical area of healthcare. Firstly, we use current clinical understanding as the basis to define requirements for wearable sensor systems capable of assessing DFU. Secondly, we review the fundamental sensing technologies employed in this field and investigate the capabilities of the resultant wearable systems, including both commercial and research-grade equipment. Finally, we discuss research trends, ongoing challenges and future opportunities for improved sensing technologies to monitor plantar loading in the diabetic foot.

Metatarsal Osteotomies for Treating Neuropathic Diabetic Foot Ulcers: A Meta-analysis

Diabetic foot ulcers (DFUs) are usually treated with conservative management based on debridement, topical agents, and nonsurgical off-loading; however, the recurrence rate following such standard care is reported to be high. In the case of recalcitrant or recurrent ulcers, a surgical off-loading technique such as the metatarsal osteotomy (MO) is indicated. Thus, the aim of this study is to conduct a meta-analysis evaluating the efficacy of MO in treating DFUs. Four relevant studies were identified, including 119 patients with 129 DFUs; all wounds were refractory to a previous conservative treatment of a mean duration of 10.9 ± 4.2 months. With a mean follow-up period of 18.2 ± 5.7 months, the weighted pooled rates were as follows: 98.7% for ulcer healing (in a mean time to heal of 6.5 ± 1.2 weeks), 4.3% for ulcer recurrence, 10.3% for ulcer transfer, 3.7% for infection, and 3.4% for nonunion. These findings were found to be noticeably better than those reported in the literature following standard care, whether associated or not to nonsurgical off-loading methods and that for all the studied outcomes. Knowing the dismal natural history of recalcitrant DFUs treated conservatively, the results of the MO techniques seems to offer a promising alternative in terms of ulcer healing and ulcer complications. In addition to complicated wounds, the indications for MO could include noncomplicated ulcers with healing delay. Level of Evidence: Level IV.

Surgical Offloading Techniques Should be Used More Often and Earlier in Treating Forefoot Diabetic Ulcers: An Evidence-Based Review

Conservative treatment is the basis for diabetic foot ulcer (DFU) management, whereas surgical treatment is usually reserved for patients with failed, recurrent, or nonresponsive infected wounds. However, many reports demonstrated good to excellent results following surgery. Evidence synthesis on surgical offloading techniques and clear guidelines regarding the timing of surgery are lacking. The present study aimed to investigate the evidence behind surgical offloading techniques and propose a cutoff time for surgical indication following failed conservative treatment of neuropathic diabetic forefoot ulcers. Electronic databases were searched from inception to identify the best evidence level articles related to non-vascular surgical treatment of DFUs, such as metatarsal head resection, resection arthroplasty, metatarsal osteotomy, Achilles tendon lengthening, gastrocnemius recession, and flexor tenotomy, that have been employed for managing DFUs. Based on the highest level of evidence available, surgery was found to generate better values than standard conservative care for all outcomes except for the transfer rate. In particular, surgical bony offloading procedures demonstrated significantly better outcomes than standard conservative nonsurgical care in terms of higher healing rates, shorter healing durations, and lower recurrence rates. Moreover, 96% of DFUs healed in <1 month following surgical bony offloading, whereas 68% of ulcers healed within 3 months after standard care. The findings could challenge the classical guidelines of DFU management. This evidence-based review indicates that surgical offloading could be used more often and be proposed earlier during the course of ulcer management. The results imply that a period of 12 weeks could be considered a reasonable cutoff value to consider surgical treatment for patients with nonhealing DFUs.

Diabetic Foot Ulcers: Current Advances in Antimicrobial Therapies and Emerging Treatments

Diabetic foot ulcers (DFUs) are very important diabetes-related lesions that can lead to serious physical consequences like amputations of limbs and equally severe social, psychological, and economic outcomes. It is reported that up to 25% of patients with diabetes develop a DFU in their lifetime, and more than half of them become infected. Therefore, it is essential to manage infection and ulcer recovery to prevent negatives outcomes. The available information plays a significant role in keeping both physicians and patients aware of the emerging therapies against DFUs. The purpose of this review is to compile the currently available approaches in the managing and treatment of DFUs, including molecular and regenerative medicine, antimicrobial and energy-based therapies, and the use of plant extracts, antimicrobial peptides, growth factors, ozone, devices, and nano-medicine, to offer an overview of the assessment of this condition.

Systemic translation of locally infiltrated epidermal growth factor in diabetic lower extremity wounds

Diabetic foot ulcer is one of the most frightened diabetic complications leading to amputation disability and early mortality. Diabetic wounds exhibit a complex networking of inflammatory cytokines, local proteases, and reactive oxygen and nitrogen species as a pathogenic polymicrobial biofilm, overall contributing to wound chronification and host homeostasis imbalance. Intralesional infiltration of epidermal growth factor (EGF) has emerged as a therapeutic alternative to diabetic wound healing, reaching responsive cells while avoiding the deleterious effect of proteases and the biofilm on the wound's surface. The present study shows that intralesional therapy with EGF is associated with the systemic attenuation of pro-inflammatory markers along with redox balance recovery. A total of 11 diabetic patients with neuropathic foot ulcers were studied before and 3 weeks after starting EGF treatment. Evaluations comprised plasma levels of pro-inflammatory, redox balance, and glycation markers. Pro-inflammatory markers such as erythrosedimentation rate, C-reactive protein, interleukin-6, soluble FAS, and macrophage inflammatory protein 1-alpha were significantly reduced by EGF therapy. Oxidative capacity, nitrite/nitrate ratio, and pentosidine were also reduced, while soluble receptor for advanced glycation end-products significantly increased. Overall, our results indicate that the local intralesional infiltration of EGF translates in systemic anti-inflammatory and antioxidant effects, as in attenuation of the glycation products' negative effects.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

A Meta-Analysis of the Outcomes of Split-Thickness Skin Graft on Diabetic Leg and Foot Ulcers

Diabetic lower limb ulcers are a serious complication to diabetes that could lead to amputation and death. Split-thickness skin graft (STSG) has been proposed by some authors to treat noninfected diabetic wounds, mainly those found in the leg and on the dorsum of the foot. No quantitative evidence synthesis over this technique has been reported in the literature. The study is a meta-analysis on the effectiveness of STSG in treating diabetic leg and foot ulcers. Electronic databases were searched from inception. No limitation was imposed on study design. Eleven studies comprising 757 patients with 759 foot/leg ulcers were included. After a mean period of 2 years, 85.5% (95% confidence interval [CI] = 0.766-0.925) of ulcers were healed over a mean time of 5.35 ± 2.25 weeks, with a recurrence rate of 4.2% (95% CI = 0.009-0.096), an infection rate of 4.4% (95% CI = 0.013-0.092), and a regrafting rate of 12.1% (95% CI = 0.053-0.212). Infection was the only reported donor site morbidity with a frequency of 1.74% (95% CI = 0.001-0.048). These weighted values are found to be noticeably superior to those reported in the literature following standard conventional care. The results of the review make STSG the ideal method to treat noninfected recurrent or recalcitrant ulcers of the leg and dorsal foot. Furthermore, the authors argue that STSG should be used more frequently in the management of such wounds. The findings should encourage future prospective investigations.

Current concepts for the evaluation and management of diabetic foot ulcers

The lifetime risk for diabetic patients to develop a diabetic foot ulcer (DFU) is 25%. In these patients, the risk of amputation is increased and the outcome deteriorates.More than 50% of non-traumatic lower-extremity amputations are related to DFU infections and 85% of all lower-extremity amputations in patients with diabetes are preceded by an ulcer; up to 70% of diabetic patients with a DFU-related amputation die within five years of their amputation.Optimal management of patients with DFUs must include clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, off-loading in high-risk patients, local wound care, diagnosis and control of osteomyelitis and ischaemia. Cite this article: EFORT Open Rev 2018;3:513-525. DOI: 10.1302/2058-5241.3.180010.

A review of genetic engineering biotechnologies for enhanced chronic wound healing

Traditional methods for addressing chronic wounds focus on correcting dysfunction by controlling extracellular elements. This review highlights technologies that take a different approach - enhancing chronic wound healing by genetic modification to wound beds. Featured cutaneous transduction/transfection methods include viral modalities (ie adenoviruses, adeno-associated viruses, retroviruses and lentiviruses) and conventional non-viral modalities (ie naked DNA injections, microseeding, liposomal reagents, particle bombardment and electroporation). Also explored are emerging technologies, focusing on the exciting capabilities of wound diagnostics such as pyrosequencing as well as site-specific nuclease editing tools such as CRISPR-Cas9 used to both transiently and permanently genetically modify resident wound bed cells. Additionally, new non-viral transfection methods (ie conjugated nanoparticles, multi-electrode arrays, and microfabricated needles and nanowires) are discussed that can potentially facilitate more efficient and safe transgene delivery to skin but also represent significant advances broadly to tissue regeneration research.

Teaching Wound Care to Family Caregivers

: This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series provide simple and useful instructions that nurses should reinforce with family caregivers who perform wound care tasks. Each article also includes an informational tear sheet-Information for Family Caregivers-that contains links to instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

Outcomes after foot surgery in people with a diabetic foot ulcer and a 12-month follow-up

OBJECTIVE

The aim of this study was to retrospectively measure the outcomes of foot-sparing surgery at one year follow-up for patients with diabetic foot ulcers (DFUs). We assessed wound healing and the need for further surgery in relation to the variables that influence healing.

METHOD

Data were retrospectively collected by reviewing the electronic files of patients attending the Wound Expert Clinic (WEC). Outcomes of surgical debridement, toe, ray and transmetatarsal amputations were assessed.

RESULTS

A total of 129 cases in 121 patients were identified for inclusion. The results demonstrated that complete wound healing was reached in 52% (61/117) of the patients within 12 months. The need for additional surgery or for major amputation was 56% (n=72/129) and 30% (n=39/129) respectively. The need for an additional procedure was particularly high after surgical debridement (75%, 33/44) and transmetatarsal amputation (64%, 7/11). Risk factors for non-healing or for a major amputation were: infection (p=0.01), ischaemia (p=0.01), a history of peripheral arterial occlusive disease (p<0.01) and smoking (p=0.01). Additional findings were that not all patients underwent vascular assessment and in half of the patients there was a delay in undergoing revascularisation.

CONCLUSION

The results of the study reveal some areas for improvement including timely revascularisation and performance of multiple debridement procedures if needed in order to save a limb.

Remote Ischemic ConditioningPromising Potential in Wound Repair in Diabetes?

Remote ischemic conditioning involves the use of a blood pressure cuff or similar device to induce brief (3-5 min) episodes of limb ischemia. This, in turn, seems to activate a group of distress signals that has shown the potential ability to improve healing of the heart muscle and other organ systems. Until recently, this has not been tested in people with diabetic foot ulcers. The purpose of this review was to provide background on remote ischemic conditioning and recent data to potentially support its use as an adjunct to healing diabetic foot ulcers and other types of tissue loss. We believe that this inexpensive therapy has the potential to be deployed and incorporated into a variety of other therapies to prime patients for healing and to reduce morbidity in patients with this common, complex, and costly complication.

Healing enhancement of diabetic wounds by locally infiltrated epidermal growth factor is associated with systemic oxidative stress reduction

The diabetic foot ulcer (DFU) is the leading cause of lower extremity amputation worldwide and is directly associated with comorbidity, disability and mortality. Oxidative stress mechanisms have been implicated in the pathogenesis of these wounds. Intra-lesional infiltration of epidermal growth factor has emerged as a potential therapeutic alternative to allow for physiological benefit while avoiding the proteolytic environment at the centre of the wound. The aim of this study was to characterise the response of patients with DFUs to epidermal growth factor treatment in terms of redox status markers. Experimental groups included patients with DFUs before and 3-4 weeks after starting treatment with epidermal growth factor; compensated and non-compensated diabetic patients without ulcers; and age-matched non-diabetic subjects. Evaluations comprised serum levels of oxidative stress and antioxidant reserve markers. Patients with DFUs exhibited the most disheveled biochemical profile, with elevated oxidative stress and low antioxidant reserves, with respect to non-ulcerated diabetic patients and to non-diabetic subjects. Epidermal growth factor intra-lesional administration was associated with a significant recovery of oxidative stress and antioxidant reserve markers. Altogether, our results indicate that epidermal growth factor intra-ulcer therapy contributes to restore systemic redox balance in patients with DFUs.

Platelet-rich plasma, bilayered acellular matrix grafting and negative pressure wound therapy in diabetic foot infection

Management and treatment of acute severe diabetic foot disease in patients with suboptimal glycaemic control is a critical issue in wound repair. This paper discusses the clinical efficacy of an aggressive surgical intervention combined with targeted use of regenerative medical therapies in limb preservation. Negative pressure wound therapy (NPWT), platelet-rich plasma (PRP), bilayered acellular matrix grafting and split-thickness skin grafting were combined to treat a patient with diabetes, foot necrotising fasciitis and gaseous gangrene. The wound was completely healed. The clinical outcome revealed that a multi-intervention strategy could be effective for large necrotising fasciitis wounds. Early clinical observation, suggests aggresive surgical intervention preserving intact tissue and targeted use of new regenerative technologies can lead to preservation of a limb.

DECLARATION OF INTEREST

The authors have received no financial support for the material presented in this study outside of the scope of standard patient care reimbursement. This work was supported by the National Natural Science Foundation of China (NO. 81500596) awarded to Dr Wuquan Deng.

Total-Contact Casting as an Adjunct to Promote Healing of Pressure Ulcers in Amputees

Partial foot amputations have become increasingly prevalent among long-lived diabetic patients. These patients have lower extremity neuropathy and are prone to ulceration at their amputation site. These ulcers are difficult to heal, and they place a significant financial and resource burden on the healthcare system. We examined the efficacy of total-contact casts (TCC) in diabetic amputees with nonhealing partial foot amputation site neuropathic ulcers. Data were collected retrospectively on all patients with amputations who were treated with a total-contact cast between December 2000 and December 2003. Seventeen patients (13 men, 4 women) with amputation site ulceration were identified. All patients were diagnosed with neuropathy secondary to diabetes and none had wound healing compromised by ischemia. The initial ulcer averaged 1,169 mm2 with a depth of 2.77 mm. Patients were treated with an average of 7.9 cast applications over 8.4 weeks; 47% (8/17) of ulcers healed, but 29% (5/17) of patients were unable to complete their recommended treatment course secondary to complications from the TCC. Of the patients who were able to complete their treatment course, the healing rate was 66.7% (8/12). The recurrence rate for healed ulcers was 63% (5/8). Partial foot amputations with neuropathic ulcers present a very difficult problem to the vascular surgeon. Patient compliance and underlying medical comorbidities limit the success rate. In patients who can complete a TCC treatment course, good short term results can be expected. However, recurrence rates are high following discontinuation of mechanical TCC off-loading.

Wound healing and treating wounds: Chronic wound care and management

In the United States, chronic ulcers--including decubitus, vascular, inflammatory, and rheumatologic subtypes--affect >6 million people, with increasing numbers anticipated in our growing elderly and diabetic populations. These wounds cause significant morbidity and mortality and lead to significant medical costs. Preventative and treatment measures include disease-specific approaches and the use of moisture retentive dressings and adjunctive topical therapies to promote healing. In this article, we discuss recent advances in wound care technology and current management guidelines for the treatment of wounds and ulcers.

Decreasing Foot Pressures While Implementing Topical Negative Pressure (Vacuum-Assisted Closure) Therapy

Over the past generation, there have been a number of significant advances in wound healing in general. Unfortunately, much of this has not translated into increased success in healing wounds on the sole of the foot. We believe that much of this therapeutic disconnect has to do with an inadequate merging of pressure off-loading technologies and active wound-healing technologies. This article discusses such a merger between removable cast walkers and topical negative pressure (also known as vacuum-assisted closure).

Literature review on the management of diabetic foot ulcer

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

Microbiology of diabetic foot infections: from Louis Pasteur to 'crime scene investigation'

Were he alive today, would Louis Pasteur still champion culture methods he pioneered over 150 years ago for identifying bacterial pathogens? Or, might he suggest that new molecular techniques may prove a better way forward for quickly detecting the true microbial diversity of wounds? As modern clinicians faced with treating complex patients with diabetic foot infections (DFI), should we still request venerated and familiar culture and sensitivity methods, or is it time to ask for newer molecular tests, such as 16S rRNA gene sequencing? Or, are molecular techniques as yet too experimental, non-specific and expensive for current clinical use? While molecular techniques help us to identify more microorganisms from a DFI, can they tell us 'who done it?', that is, which are the causative pathogens and which are merely colonizers? Furthermore, can molecular techniques provide clinically relevant, rapid information on the virulence of wound isolates and their antibiotic sensitivities? We herein review current knowledge on the microbiology of DFI, from standard culture methods to the current era of rapid and comprehensive 'crime scene investigation' (CSI) techniques.

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

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

Strategy of surgical management of peripheral neuropathy form of diabetic foot syndrome in ghana

Introduction. Foot disorders such as ulceration, infection, and gangrene which are often due to diabetes mellitus are some major causes of morbidity and high amputation. Aim. This study aims to use a group of methods for the management of diabetic foot ulcers (DFU) in order to salvage the lower limb so as to reduce the rate of high amputations of the lower extremity. Materials and Methods. A group of different advanced methods for the management of DFU such as sharp debridement of ulcers, application of vacuum therapy, and other forms of reconstructive plastic surgical procedures were used. Data collection was done at 3 different hospitals where the treatments were given. Results. Fifty-four patients with type 2 diabetes mellitus were enrolled in the current study: females n = 37 (68.51%) and males n = 17 (31.49%) with different stages of PEDIS classification. They underwent different methods of surgical management: debridement, vacuum therapy (some constructed from locally used materials), and skin grafting giving good and fast results. Only 4 had below knee amputations. Conclusion. Using advanced surgical wound management including reconstructive plastic surgical procedures, it was possible to reduce the rate of high amputations of the lower limb.

The system of care for the diabetic foot: objectives, outcomes, and opportunities

Most cases of lower extremity limb loss in the United States occur among people with diabetes who have a diabetic foot ulcer (DFU). These DFUs and the associated limb loss that may occur lead to excess healthcare costs and have a large negative impact on mobility, psychosocial well-being, and quality of life. The strategies for DFU prevention and management are evolving, but the implementation of these prevention and management strategies remains challenging. Barriers to implementation include poor access to primary medical care; patient beliefs and lack of adherence to medical advice; delays in DFU recognition; limited healthcare resources and practice heterogeneity of specialists. Herein, we review the contemporary outcomes of DFU prevention and management to provide a framework for prioritizing quality improvement efforts within a resource-limited healthcare environment.

Evidence-based topical management of chronic wounds according to the T.I.M.E. principle

The number of patients suffering from chronic wound healing disorders in Germany alone is estimated to be 2.5-4 million. Therapy related expenses reach 5-8 billion Euros annually. This number is partially caused by costly dressing changes due to non-standardized approaches and the application of non-evidence-based topical wound therapies. The purpose of this paper is to elucidate a straightforward principle for the management of chronic wounds, and to review the available evidence for the particular therapy options. The T.I.M.E.-principle (Tissue management, Inflammation and infection control, Moisture balance, Epithelial [edge] advancement) was chosen as a systematic strategy for wound bed preparation. Literature was retrieved from the PubMed and Cochrane Library databases and subjected to selective analysis. Topical wound management should be carried out according to a standardized principle and should further be synchronized to the phases of wound healing. Despite the broad implementation of these products in clinical practice, often no benefit exists in the rate of healing, when evaluated in meta-analyses or systematic reviews. This insufficient evidence is additionally limited by varying study designs. In case of non-superiority, the results suggest to prefer relatively inexpensive wound dressings over expensive alternatives. Arbitrary endpoints to prove the effectiveness of wound dressings, contribute to the random use of such therapies. Defining rational endpoints for future studies as well as the deployment of structured therapy strategies will be essential for the economical and evidence-based management of chronic wounds.

Detection of Escherichia coli and associated β-lactamases genes from diabetic foot ulcers by multiplex PCR and molecular modeling and docking of SHV-1, TEM-1, and OXA-1 β-lactamases with clindamycin and piperacillin-tazobactam

Diabetic foot ulcer (DFU) is a common and devastating complication in diabetes. Antimicrobial resistance mediated by extended-spectrum β-lactamases (ESBLs) production by bacteria is considered to be a major threat for foot amputation. The present study deals with the detection of Escherichia coli and the prevalence of bla_TEM, bla_SHV and bla_OXA genes directly from biopsy and swab of foot ulcers of diabetic patients. In total, 116 DFU patients were screened, of which 42 suffering with severe DFUs were selected for this study. Altogether 16 E. coli strains were successfully isolated from biopsy and/or swab samples of 15 (35.71%) patients. ESBL production was noted in 12 (75%) strains. Amplification of β-lactamase genes by multiplex PCR showed the presence of bla_CTX-M like genes in 10 strains, bla_TEM and bla_OXA in 9 strains each, and bla_SHV in 8 of the total 16 strains of E. coli. Out of the ten antibiotics tested, E. coli strains were found to be resistant to ampicillin (75%), cefoxitin (56.25%), cefazolin (50%), meropenem (37.5%), cefoperazone (25%), cefepime (31.25%), ceftazidime (56.25%), and cefotaxime (68.75%) but all showed sensitivity (100%) to clindamycin and piperacillin-tazobactam. 3D models of the most prevalent variants of β-lactamases namely TEM-1, SHV-1, OXA-1, and ESBL namely CTX-M-15 were predicted and docking was performed with clindamycin and piperacillin-tazobactam to reveal the molecular basis of drug sensitivity. Docking showed the best docking score with significant interactions, forming hydrogen bond, Van der Waals and polar level interaction with active site residues. Findings of the present study may provide useful insights for the development of new antibiotic drugs and may also prevent ESBLs-mediated resistance problem in DFU. The novel multiplex PCR assay designed in this study may be routinely used in clinical diagnostics of E. coli and associated bla_TEM, bla_SHV, and bla_OXA like genes.

Clinical efficacy of the pan metatarsal head resection as a curative procedure in patients with diabetes mellitus and neuropathic forefoot wounds

OBJECTIVE

To evaluate the safety and efficacy of the pan metatarsal head resection (PMHR) compared with nonsurgical management of wounds in the forefoot in people with diabetes.

METHODS

The authors evaluated 92 patients with diabetes (66.3% male), with ulcers classified as University of Texas grade 1A or 2A at the plantar aspect of the forefoot using a case-control model. Cases were patients treated with multiple metatarsal head resections for multiple metatarsal head wounds, and controls received standard nonsurgical care. Both groups received standard off-loading and wound care. Outcomes included time to healing, reulceration, infection, and amputation.

RESULTS

Patients in the surgery group (SG) healed significantly faster than those in the standard therapy group (ST; 84.2 ± 39.9 days for the ST vs 60.1 ± 27.9 days for the SG; P = .003) and had fewer recurrent ulcers (39.1% for the ST vs 15.2% for the SG; P = .02; odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.3-9.7) and infections during 1 year of follow-up (64.5% for the ST vs 35.5% for the SG; P = .047; OR = 2.4; 95% CI = 1.0-6.0). There was no significant difference in the proportion of patients receiving an incident amputation in the follow-up period (13.0% for the ST vs 6.5% for the SG; P = .5).

CONCLUSION

The results of this study suggest that the PMHR may be associated with shorter times to healing and lower morbidity compared with standard care alone in patients without digital gangrene and with multiple plantar forefoot ulcers.