Is Total Contact Casting Effective for Treating Diabetic Foot Ulcers?

Evidence based review of literature on detriments to healing of diabetic foot ulcers

BACKGROUND

Diabetes mellitus places a substantial burden on society worldwide. Diabetic foot ulcers are a challenging problem for clinicians. Seven generally accepted detriments to healing of diabetic foot ulcers were identified: infection, glycaemic control, vascular supply, smoking, nutrition, deformity and offloading. The aim of this paper is to present a comprehensive evidence based review of the literature available on detriments to healing of diabetic foot ulcers.

METHOD

A research question was generated for each of the detriments to healing and a comprehensive review of the literature was performed using the Pubmed database in July 2014. All articles were assessed for relevancy and a level of evidence was assigned. An analysis of the total body of literature was used to assign a grade of recommendation to each detriment.

RESULTS

Grade A recommendation was assigned to offloading as there was good evidence supporting this intervention. Grade B recommendation was assigned to deformity as there was fair evidence consistent with the hypothesis. Infection and vascular supply had poor quality evidence supporting the research question and grade C recommendation was assigned. Grade I recommendation was assigned to glycaemic control, smoking and nutrition as there was insufficient and conflicting evidence available.

CONCLUSION

Our literature review revealed good evidence for some factors and insufficient literature on others. Further studies are needed to provide quality evidence regarding detriments to healing of diabetic ulcers.

Vacuum cushioned removable cast walkers reduce foot loading in patients with diabetes mellitus

BACKGROUND

Diabetes mellitus is one of the most common diseases worldwide and the number of patients is expected to increase dramatically in future. Plantar ulceration is partly caused by high plantar pressures and a major complication in diabetic patients.

PURPOSE

The aim of this study was to investigate the pressure-relieving effects of two vacuum orthoses in patients with diabetes mellitus.

METHODS

Twenty patients with diabetes mellitus were included. They presented with plantar callosities but no ulceration. Exclusion criteria included the use of walking aids and other systemic diseases. Plantar pressure distribution was measured with sensor insoles (Pedar-X, Novel GmbH) during walking in two vacuum orthoses, a post-operative shoe and an off-the-shelf shoe as reference condition. Statistical analysis was conducted using Friedman and Wilcoxon signed-rank tests.

RESULTS

Significant differences in plantar pressure distribution were found between the four walking conditions. The contact area increased in the midfoot with the vacuum orthoses. Maximum force and peak pressures showed a significant decrease under the rearfoot and forefoot and increased in the midfoot area during walking with both vacuum orthoses. The high-cut vacuum orthosis revealed equal pressure relief under the forefoot and significantly lower rearfoot pressures compared to the post-operative shoe.

CONCLUSIONS

The vacuum orthoses demonstrated a comparable pressure-relieving efficacy under the forefoot to post-operative shoes. Using vacuum orthosis significantly benefited re-distribution of plantar pressure and the roll-over process. Clinical significance of the pressure-relieving efficacy could not be confirmed in this investigation and has to be addressed in further studies.