Pathways to diabetic limb amputation. Basis for prevention

The Prevalence of Contact Allergies for Wound Dressings in Patients With Diabetic Foot Ulcers (PAID Study), an Observational Prospective Trial

This investigator initiated prospective observational study investigates the prevalence of contact allergies in patients with a Diabetic Foot Ulcer (DFU). Patients with a DFU received a combined PATCH-test (a test used to investigate the origin of an allergic reaction on the skin) at the upper back, with the European baseline series, the European leg ulcer series, and local used material for leg ulcers. A total of 108 patients with DFU were included of which 86 (79.6%) were male, and 9 (8.3%) and 99 (91.7%) patients had Type 1 and Type 2 diabetes, respectively. Twenty-one patients had a sensitization in the standard series, 30 patients in the leg ulcer series, and 11 patients in both series. Two patients had a positive reaction for one of the local used materials. Most frequent sensitizations were found for Perubalsem (N = 6) and Fragrance-Mix II (N = 4) in the standard series. A sensitization for Povidone-Iodine (N = 20) was most frequently seen in the leg ulcer series. In the local used materials a sensitization for silver sulfadiazine (N = 1) and cutimed-gel (n = 1) were seen. In conclusion, this study provides novel information about sensitizations in patients with DFU, but more research is needed to demonstrate the relationship between allergic reactions and delayed wound healing. The study protocol was registered in www.clinicaltrials.gov (NCT04085705, PAID study).

Longitudinal Determination of Diabetes Complications and Other Clinical Variables as Risk Factors for Diabetic Ketoacidosis in Type 1 Diabetes

OBJECTIVE

We aimed to determine whether diabetes complications, such as kidney disease that may impair acid-base buffering capacity, independently predict the risk of subsequent diabetic ketoacidosis (DKA).

RESEARCH DESIGN AND METHODS

We accessed previously collected 34-year data from the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications study through public data access. Multivariable Cox proportional hazards models with time-varying exposures and covariates were used to examine the associations of macrovascular disease and early and late stages of neuropathy, nephropathy, and retinopathy, with subsequent DKA occurrence as the outcome.

RESULTS

Of 1,441 participants, 297 experienced 488 DKA events over follow-up. Major adverse cardiovascular events [hazard ratio (HR) 3.16, 95% CI 1.57-6.35, P = 0.001] and late-stage neuropathy, which comprised serious foot ulcer or amputation (HR 1.59, 95% CI 1.04-2.45, P = 0.03) were independently associated with higher DKA risk. Higher risk was also associated with shorter diabetes duration (HR 0.76, 95% CI 0.64-0.91, P = 0.002), female sex (HR 2.04, 95% CI 1.56-2.67, P < 0.001), current insulin pump use (HR 3.04, 95% CI 2.29-4.02, P < 0.001), higher time-updated HbA1c (per additional 1%: HR 1.39, 95% CI 1.29-1.50, P < 0.001), and higher current insulin dose (per 1 additional unit/kg/day: HR 2.32, 95% CI 1.62-3.33, P < 0.001).

CONCLUSIONS

A major cardiovascular event, foot ulcer, or amputation confers the greatest risk of future DKA independent of previously recognized risk factors, implying a need to target patients with these events for DKA prevention interventions, such as self-management skills for metabolic control, management of depression, and DKA education.

Partial Calcanectomy: Patient Selection Process and the Secrets to Optimizing Outcomes

Limb salvage in patients with chronic heel wounds is a challenging and can be wrought with complications. A partial calcanectomy is becoming more popular in an effort to try to preserve limb length. Proper patient selection is of outmost importance in order to try and achieve optimal outcome. The article reviews and analyzes the current literature in order to aid the surgeon.

Proangiogenic Cyclic Peptide Nanotubes for Diabetic Wound Healing

An intricate biochemical system of coordinated cellular reactions is involved in restoring damaged tissue after wounds. In chronic wounds, such as diabetic foot ulcers, poor angiogenesis is a common stumbling block due to elevated glucose levels, increased proteolytic enzyme activity, and decreased production of growth factors. While various strategies, including modulation of inflammatory cells, administration of growth factors, and therapies involving stem cells or genes, have been explored to promote angiogenesis, they often suffer from limitations such as poor biodistribution, immunological rejection, administration/dosing, and proteolytic instability. Glycosaminoglycans, such as heparan sulfate, facilitate growth factor interactions with their receptors to induce angiogenic signaling, but their exogenous administration is hindered by poor stability, low serum half-life, and immunogenicity. Cyclic peptides, known for their structural stability and specificity, offer a promising alternative for inducing angiogenesis upon functional modifications. In this work, we developed heparan sulfate (HS)-mimetic cyclic peptide nanotubes (CPNTs) grafted with bioactive groups to enhance angiogenesis without using exogenous growth factors, drugs, or supplements. These CPNTs incorporate glutamic acid, serine, and sulfonated lysine to mimic the functional groups in heparin. The sulfonated cyclic hexapeptide nanotubes developed from DPro-LTrp-DLeu-LSer-DGlu-LLys demonstrated significant proangiogenic activity in HUVECs under hyperglycemic conditions; enhanced endothelial cell motility, invasion, and tube formation; and upregulation of proangiogenic genes and proteins. These HS-mimicking nanotubes have shown a strong potential for promoting impaired angiogenesis, without incorporating exogenous growth factors, and show strong potential in treating diabetic wounds. To the best of our knowledge, this is the first report on the use of HS-mimetic proangiogenic cyclic peptide nanotubes for diabetic wound healing.

Radiographic Bone Healing in Minimally Invasive Floating Metatarsal Osteotomy for Neuropathic Plantar Metatarsal Head Ulcers - A Retrospective Cohort Study

Minimally invasive floating metatarsal osteotomy is an option for treating neuropathic ulcers under the metatarsal heads. This study presents the radiographic results of the floating metatarsal osteotomy. We reviewed files and radiographs at least 4 months after a floating metatarsal osteotomy in patients with diabetic neuropathy. In 71 osteotomies in 54 patients with late onset diabetes (mean age 61 ± 9, mean HbA1c 7.9 ± 1.9%), the primary ulcer healed within 3.5 ± 1.4 weeks. Of 66 osteotomies where radiographs were available 10 had non-union (15%, all asymptomatic), 15 (23%) had hypertrophic callus formation and 41 (62%) had normal union. One patient developed an ulcer under the hypertrophic callus. This necessitated callus resection. Asymptomatic non-union may happen in 15% of floating osteotomies, but the osteotomies appear to be relatively safe and effective for neuropathic plantar metatarsal head ulcers. Hypertropic callus causing local re-ulceration is rare and can be managed surgically.

Chlorhexidine vs Routine Foot Washing to Prevent Diabetic Foot Ulcers: A Randomized Clinical Trial

Importance

Foot ulcers are a common and feared complication for people with diabetes because 20% of foot ulcers become infected and lead to a lower extremity amputation.

Objective

To evaluate the effect of daily foot care using chlorhexidine wipes vs soap-and-water wipes for 1 year on the risk of developing new foot complications in veterans with diabetes.

Design, Setting, and Participants

This double-blind, placebo-controlled, phase 2b randomized clinical trial was conducted at the Baltimore Veterans Affairs (VA) Medical Center between January 2019 to January 2023. Veterans were eligible if they had a diabetes diagnosis, were at high risk for diabetic foot complications, were ambulatory, had both feet, and did not have a current foot infection. Participants were randomly assigned 1:1 to receive either soap-and-water wipes (control group) or 2% chlorhexidine wipes (chlorhexidine group). Intention-to-treat data analysis was conducted from October 5, 2023, to April 24, 2024.

Intervention

Daily use of a 2% chlorhexidine wipe or a soap-and-water wipe on the feet for 1 year. Wipes were nearly identical in color, size, shape, thickness, feel, and scent. Both chlorhexidine and control groups received the same lotion for application on the feet after wipe use and education on foot self-care.

Main Outcomes and Measures

The primary outcome was time in days from randomization to new foot complication, including chronic foot ulcer, foot infection, or foot amputation.

Results

A total of 175 participants (170 males [97%]; mean [SD] age at enrollment, 68 [9] years; 1 Asian [1%], 117 Black or African American [67%], 53 White [30%] individuals) were randomly assigned to the chlorhexidine group (n = 88) or the control group (n = 87). Twelve participants (14%) in the chlorhexidine group and 14 participants (16%) in the control group developed a new foot complication within 1 year. Median (IQR) time from randomization to development of a new foot complication was 232 (115-315) days. The reduction in hazard of new foot complications in the chlorhexidine group compared with the control group was not significant (hazard ratio, 0.83; 95% CI, 0.39-1.80). The intervention was well tolerated, with 145 participants (83%) continuing it over the study period. Sixty adverse events occurred, but none was related to the study products or procedures.

Conclusions and Relevance

This randomized clinical trial found that daily use of chlorhexidine wipes for foot washing for 1 year did not lead to a significant reduction in the risk of new foot complications compared with daily use of soap-and-water wipes. The intervention was well tolerated, and the trial provides important lessons for future studies on diabetic foot ulcer prevention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03503370.

Prevalence and predictors of infected diabetic foot ulcers (DFU) and DFU-related osteomyelitis amongst industrial workers wearing occupational safety footwear

Professionals like deep-miners and factory-workers wear specialized safety-shoes to protect against occupational hazards (OF). The risk factors, clinico-microbiologic profile and complications of diabetic foot ulcers (DFU) in these professionals remain unexplored. A cross-sectional observational study was conducted to describe the unique clinico-microbiologic profile of DFU in those wearing occupational-footwear (OF) and find risk factors for DFU related osteomyelitis in them. Of 331 DFU cases seen over 5 years, those wearing OF (n = 107, 68 underground-miners and 39 steel-factory-workers) had high prevalence of forefoot-DFU (81.3%), dorsal-DFU ( 58.9%), recurrent-DFU (31.8%) and of polymicrobial infections (16.8%). Those with osteomyelitis in the OF group ( n = 53) were younger (53.3 vs. 57, p = 0.02), had higher prevalence of peripheral arterial disease (41.5% vs. 24.1%), past-amputation (28.3% vs. 11.1%), higher SINBAD scores, and were also less likely to change occupational-footwear at < = 6-month-interval (22.6% vs. 55.6%) than those without osteomyelitis (p < 0.05 for all). Increasing age, history of past amputation, CRP and reduced frequency of changing the OF were significant positive risk factors for osteomyelitis. OF change at < = 6-month-interval had a protective effect against osteomyelitis (OR : 0.21, C.I 0.07-0.54, p = 0.002) as well as for recurrence (OR : 15, C.I.: 0.04-0.46, p = 0.002) of DFU. Existing national standards for OF manufacturing and regulations regarding their use in India are inadequate and must be made more stringent for professionals with diabetes, especially those at high risk for DFU like the elderly, history of past amputation or those with LOPS. They need detailed foot-measurements for proper fit, should wear OF always at their work-place and change OF frequently for adequate against DFU-related osteomyelitis as also, recurrent DFU.

Volumetric Ultrasound of the Plantar Soft Tissue Under Bodyweight Loading

OBJECTIVE

This work aims to develop a device capable of acquiring volumetric scans of the plantar soft tissue in naturally loaded and unloaded states using ultrasound B-mode imaging and shear wave elastography.

METHODS

Materials were investigated for acoustic transmission and bodyweight loading. A mechanical scanning apparatus was constructed using a compatible load bearing material and two perpendicular linear actuators. Custom software was developed to control the scanner, record subject and scan information, and reconstruct acquired ultrasound images and shear wave speed values into a volume. The system was evaluated using custom-developed ultrasound phantoms.

RESULTS

Plastic materials reduced axial and lateral resolution by 0.25 - 0.5 mm and reduced SWE values by 0.8 to 26 kPa. The developed system produced volumetric scans within 0.1 to 1.6 mm of expected dimensions on a geometric phantom compared to 0 to 0.6 mm in standard computed tomography. Acoustic thermal increases were 0 °C for B-mode and .9 to 2.9 °C for SWE. Volumes of an anatomically realistic phantom and a pilot scan yielded clear anatomic features.

CONCLUSION

The resulting system is capable of producing volumetric plantar soft tissue scans in both B-mode and shear wave elastography with resolution on par with existing volumetric medical imaging systems.

SIGNIFICANCE

This system images plantar soft tissue volumes under physiologic loads.

Pilot Study: Human Adipose Tissue Allograft for Fat Pad Defects in Patients With Preulcerative Lesions

Background

Loss or displacement of a fat pad on the foot increases plantar pressure, leading to pain and plantar ulcers. These ulcers, especially in patients with diabetic neuropathy, have high recurrence rates, often resulting in amputations. Standard of care focuses on reducing plantar pressure with shoe padding or orthotic devices, leaving the restoration of the fat pad as an unmet medical need. To address this, a human cryopreserved adipose tissue (hCAT) allograft has been developed to repair adipose tissue defects.

Methods

Scientific characterization of hCAT included assessments of its structural properties, immunogenicity, persistence, and remodeling in both in vitro and in vivo models. The incidence of adverse events and ulcer recurrence was analyzed retrospectively in 12 patients with diabetic neuropathy with preulcerative lesions who received 1.5-3.0 mL subcutaneous hCAT implants in areas with fat pad defects.

Results

When implanted in patients, hCAT remained palpable at the implantation sites, and no ulcerations occurred for an average of 6.4 months (range, 2-10 months). No product-related adverse events have been recorded to date. Long-term follow-up for implanted patients is ongoing.

Conclusions

Use of hCAT seems to be safe and potentially beneficial for managing patients at risk for plantar ulcerations. Further studies are warranted to evaluate hCAT's potential to manage patients at high risk for plantar ulcer formation.

Assessment of Risk Factors Leading to Amputation Among Diabetic Septic Foot Patients in Khartoum, Sudan

Introduction  Diabetes is a rapidly growing global health concern, with the World Health Organization (WHO) estimating that 300 million adults will have diabetes by 2025. This chronic condition is associated with complications, including nephropathy, retinopathy, neuropathy, cardiovascular disease, and diabetic foot ulcers (DFUs), which can lead to amputation. Diabetic septic foot (DSF), a severe form of diabetic foot disease, is defined by the WHO as the presence of infection, ulceration, or tissue destruction in the lower limb, often accompanied by neurological abnormalities, peripheral vascular disease, and metabolic complications of diabetes. In Sudan, the incidence of lower limb amputations due to DSF is increasing, with various healthcare centers employing different management strategies, making it challenging to identify which factors are most strongly linked to the highest rates of amputations. This study aims to identify the key risk factors contributing to amputations in patients with diabetic foot syndrome (DFS) in Khartoum, Sudan. Specifically, it seeks to assess the common risk factors for amputation in diabetic septic foot patients at hospital wards and dressing centers in Khartoum State, Sudan. Objectives include identifying risk factors associated with amputations, determining the types and frequency of amputations, and evaluating diabetes control and foot self-care practices.  Methods This was a descriptive cross-sectional study that was conducted anonymously between 01/11/2017 and 08/11/2017 in various hospital wards and dressing centers in Khartoum, Sudan, on 46 diabetic septic foot patients. Data was collected using an interview questionnaire and checklist administered to the attending patients. Quantitative data was analyzed using IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. This paper aims to explore the pathophysiology, risk factors, and clinical management of diabetic foot complications, with a focus on preventing the devastating outcome of amputation.  Results The findings revealed that the most significant risk factors for amputation included a raised HbA1c level (74%), male gender (78%), age over 50 years (96%), and a history of preceding non-healing ulcers (93.5%). Other factors, such as smoking, diabetes-related comorbidities, and the type of diabetes management, showed no significant association with amputation. Normal saline and iodine were the most commonly used wound care solutions (52%). Regarding foot care habits, the most frequently practiced measures among patients included wearing special diabetic shoes (63%), avoiding walking barefoot (63%), and refraining from smoking (59%). Conclusions This study identified key risk factors for amputations in diabetic septic foot (DSF) patients, including elevated HbA1C levels, male gender, age over 50, and a history of unhealing ulcers, with poor foot care practices contributing to higher amputation rates. The findings highlight the importance of glycemic control, foot hygiene, and patient education in preventing amputations. Additionally, the study underscores the need for comprehensive management strategies that address both metabolic control and foot care, particularly in resource-limited settings. These insights can guide local healthcare policies focused on prevention, early intervention, and better resource allocation to reduce diabetes-related complications and improve patient outcomes.

Efficacy and Safety of Topical Solution of Diperoxochloric Acid for Neuropathic Diabetic Foot Ulcer: Results from a Phase 3, Multicentre, Randomized, Active-controlled, Parallel-group Study

Diabetic foot ulcer (DFU), if untreated, accounts for lower-limb amputations affecting patients' quality-of-life. Diperoxochloric acid (DPOCL) is known to heal DFU by its antibacterial and fibroblast stimulating activity. This was a phase 3, multicentre, randomized, double-blind, active-controlled, parallel-group study conducted to evaluate the efficacy and safety of topic solution of DPOCL compared with isotonic sodium chloride solution (ISCL). Adult patients with type 1 or 2 diabetes with random blood glucose levels of <250 mg/dL, with ≤ than three full-thickness foot ulcers were enrolled. Primary efficacy endpoint was complete wound closure and secondary was wound surface area. Adverse events were analyzed as safety endpoint. Of 311 enrolled patients, 289 were randomized 1:1 to DPOCL (139) and ISCL (150) treatment (10-weeks [8-Visits]). Percentage of patients with complete wound closure at visit-8, were significantly higher (P = .0156) in DPOCL arm (76% [105/139]) compared to ISCL (62% [93/150]) arm. At end-of-study, mean wound surface area in DPOCL arm (0.639 cm2) was significantly lower (P = .0209) compared to ISCL (0.818 cm2) arm. One death was reported in control arm which was not considered as treatment-related. No important safety finding were observed. Results indicate that, DPOCL can be considered as effective and safe treatment option for DFU compared to ISCL, although future confirmatory studies are warranted.

Outcomes in Patients With Heel Ulcerations that Underwent Below the Knee Amputations Versus Vertical Contour Calcanectomy: Importance of Selection Criteria

The aim of the study was to compare preoperative factors and postoperative outcomes in patients with heel ulcerations that primarily had a transtibial (below the knee) amputation (N = 38) versus vertical contour calcanectomy (n = 62). The groups had no statistical difference between their Charlson Comorbidity Index Score, a prognostic score of 10-year survival in patients with multiple comorbidities. The odds of primary closure were 21.1 times higher in patients that underwent below knee amputation compared to patients that underwent vertical contour calcanectomy (OR 21.1 [95% CI 3.89-114.21]). The odds of positive soft tissue culture at time of closure were 17.1 times higher for patients that underwent vertical contour calcanectomy (OR 17.1 [95% CI 5.40-54.16]). The odds of a patent posterior tibial artery were 3.3 times higher for patients that underwent vertical contour calcanectomy (OR 3.3 [95% 1.09-10.09]). The secondary aim of the study was to evaluate preoperative factors and postoperative outcomes in patients with failed vertical contour calcanectomy, defined as needing a below knee amputation. The odds of vertical contour calcanectomy failure was 13.7 times higher in male patients (OR 13.7 [95% CI 1.80-107.60]). Vertical contour calcanectomy failure was 5.7 times higher in patients with renal disease (OR 5.7 [95% CI 1.10-30.30]), and vertical contour calcanectomy failure was 16.1 times higher for patients who needed additional surgery post closure (OR 16.1 [95% CI 1.40-183.20]).

Advancements and best practices in diabetic foot Care: A comprehensive review of global progress

Diabetic foot care has become a critical focus in global healthcare due to the rising prevalence of diabetes and its associated complications. This review aims to consolidate recent advancements and best practices in managing diabetic foot conditions, encompassing foot ulcers, neuropathy, vascular disease, and the risk of amputation. Emphasizing a multidisciplinary approach, the review advocates for collaboration among diabetologists, podiatrists, vascular surgeons, and wound care specialists to enhance patient outcomes. Key advancements highlighted include innovative wound care techniques like advanced dressings and bioengineered skin substitutes, alongside effective offloading devices to prevent pressure-related injuries. Early detection and intervention strategies for neuropathy and vascular disease are underscored, with a particular focus on vascular evaluation as a baseline investigation, including Ankle-Brachial Index (ABI) and Toe-Brachial Index (TBI) assessments by trained podiatrists and the use of arterial color Doppler/duplex scans for suspected Peripheral Artery Disease (PAD). The review also examines the impact of technological innovations such as telemedicine and wearable devices, facilitating enhanced patient monitoring and timely interventions. It stresses the importance of patient education and self-care practices in mitigating complications. Addressing global disparities, the review advocates for accessible and equitable healthcare services across diverse regions. Concluding with recommendations for future research and policy initiatives, this review serves as a vital resource for healthcare professionals, policymakers, and researchers committed to advancing diabetic foot care and improving global patient outcomes.

Minimally-invasive Distal Metatarsal Diaphyseal Osteotomy in the Treatment of Plantar Ulcer in the Diabetic Foot: A Case Report

The diabetic foot consumes a large number of resources and has a profound negative impact on quality of life, representing the major non-traumatic cause of lower limb amputation in adults. The present report describes a diabetic patient with a recurrent plantar ulcer in the topography of the heads of the second, third, and fourth metatarsals. The patient was treated using the distal metatarsal diaphyseal osteotomy (DMDO) technique in these bones, an Akin-type percutaneous osteotomy in the proximal phalanx of the hallux, and debridement. The 5-year postoperative follow-up revealed good outcomes regarding healing and prevention of new episodes.

An overview of current developments and methods for identifying diabetic foot ulcers: A survey

Diabetic foot ulcers (DFUs) present a substantial health risk across diverse age groups, creating challenges for healthcare professionals in the accurate classification and grading. DFU plays a crucial role in automated health monitoring and diagnosis systems, where the integration of medical imaging, computer vision, statistical analysis, and gait information is essential for comprehensive understanding and effective management. Diagnosing DFU is imperative, as it plays a major role in the processes of diagnosis, treatment planning, and neuropathy research within automated health monitoring and diagnosis systems. To address this, various machine learning and deep learning‐based methodologies have emerged in the literature to support healthcare practitioners in achieving improved diagnostic analyses for DFU. This survey paper investigates various diagnostic methodologies for DFU, spanning traditional statistical approaches to cutting‐edge deep learning techniques. It systematically reviews key stages involved in diabetic foot ulcer classification (DFUC) methods, including preprocessing, feature extraction, and classification, explaining their benefits and drawbacks. The investigation extends to exploring state‐of‐the‐art convolutional neural network models tailored for DFUC, involving extensive experiments with data augmentation and transfer learning methods. The overview also outlines datasets commonly employed for evaluating DFUC methodologies. Recognizing that neuropathy and reduced blood flow in the lower limbs might be caused by atherosclerotic blood vessels, this paper provides recommendations to researchers and practitioners involved in routine medical therapy to prevent substantial complications. Apart from reviewing prior literature, this survey aims to influence the future of DFU diagnostics by outlining prospective research directions, particularly in the domains of personalized and intelligent healthcare. Finally, this overview is to contribute to the continual evolution of DFU diagnosis in order to provide more effective and customized medical care.

This article is categorized under:

The Potential Impact of SGLT2-I in Diabetic Foot Prevention: Promising Pathophysiologic Implications, State of the Art, and Future Perspectives-A Narrative Review

The impact of diabetic foot (DF) on the healthcare system represents a major public health problem, leading to a considerable clinical and economic burden. The factors contributing to DF's development and progression are strongly interconnected, including metabolic causes, neuropathy, arteriopathy, and inflammatory changes. Sodium-glucose cotransporter 2 inhibitors (SGLT2-i), novel oral hypoglycemic drugs used as an adjunct to standard treatment, have recently changed the pharmacological management of diabetes. Nevertheless, data about the risk of limb amputation, discordant and limited to canagliflozin, which is currently avoided in the case of peripheral artery disease, have potentially discouraged the design of specific studies targeting DF. There is good evidence for the single immunomodulatory, neuroprotective, and beneficial vascular effects of SGLT2-i. Still, there is no clinical evidence about the early use of SGLT2-i in diabetic foot due to the lack of longitudinal and prospective studies proving the effect of these drugs without confounders. This narrative review aims to discuss the main evidence about the impact of SGLT2-i on the three complications of diabetes implicated in the development of DF, the state of the art, and the potential future implications.

Causal associations between type 2 diabetes mellitus, glycemic traits, dietary habits and the risk of pressure ulcers: univariable, bidirectional and multivariable Mendelian randomization

Objective

Previous research has established a connection between Type 2 Diabetes Mellitus (T2DM), glycemic traits, dietary habits, and the risk of Pressure Ulcers (PUs). The aim of our study is to disentangle any potential causal relationship between T2DM, glycemic traits, and dietary factors, and the risk of PUs.

Methods

The exposure and outcome datasets were sourced from the IEU Open GWAS project, the Meta-Analyses of Glucose and Insulin-related traits Consortium (MAGIC), and the FinnGen biobank, respectively. The primary MR analysis method employed was the inverse variance-weighted method. Furthermore, we employed multivariable MR (MVMR) adjusting for BMI. Then, we investigated the possibility of a reverse association between glycemic traits and PUs through bidirectional MR. Finally, Heterogeneity and pleiotropic analysis were conducted to ensure the accuracy and robustness of the results.

Results

The findings revealed that T2DM (OR = 1.282, 95% CI: 1.138-1.445, p < 0.001) and Fasting Glucose (FG; OR = 2.111, 95% CI: 1.080-4.129, p = 0.029) were associated with an increased risk of PUs, while salad/raw vegetable intake (OR: 0.014; 95% CI: 0.001-0.278; p = 0.005) was identified as a protective element. However, no other dietary elements demonstrated a statistically significant causality with PUs. In addition, in the reverse direction, there were positive correlation between genetic susceptibility to PUs and an increase in FG (OR: 1.007, 95% CI: 1.000-1.013, p = 0.048) and Fasting Insulin (FI; OR: 1.012, 95% CI: 1.003-1.022, p = 0.011). MVMR results indicated that the causal effect of T2DM on PUs was independent of BMI (OR: 1.260, 95% CI: 1.112-1.427, p < 0.001). These results remained robust when considering weak instrument bias, pleiotropy, and heterogeneity.

Conclusion

This study establishes a causal link between genetically predicted T2DM, FG and an increased risk of PUs. Conversely, Salad/raw vegetable intake is significantly inversely associated with PUs. Simultaneously, we identified two downstream effector factor (FG and FI) that were associated with PUs. These findings may have clinical implications for both prevention and treatment.

The Association of HbA1c Variability with 12 Week and 12 Month Outcomes on Diabetes Related Foot Ulcer Healing

INTRODUCTION

This study aimed to determine the relationship between HbA1c variability and foot ulcer healing at 12 weeks and 12 months.

METHODS

Using National Diabetic Foot Care Audit (NDFA) and hospital records, demographics, baseline ulcer characteristics and healing outcomes for subjects presenting with a foot ulcer between 2017-2022 were collected at 12 weeks and 12 months. Subjects had diabetes duration > 3 years and ≥ 3 HbA1c recordings in the 5 years prior to presentation.

RESULTS

At 12 weeks, factors associated with an active ulcer were presence on hind foot (adjusted odds ratios) (2.1 [95% CI 1.3-3.7]), ischaemia (2.1 [95% CI:1.4-3.2]), area > 1 cm2 (2.7 [95% CI:1.7-4.2]) and diabetes duration > 24 years vs 3-10 (AOR 2.0 [95% CI 1.2-3.5]). After adjustment, HbA1c variability 6-10 mmol/mol and > 14.5 mmol/mol had AOR of 1.76 (95% CI 1.1-2.8; p = 0.0192) and 1.5 (95% CI 0.9-2.6; p = 0.1148) of an active ulcer at 12 weeks vs variability < 6 mmol/mol. At 12 months, ischaemia (AOR 2.4 [95% CI 1.5-3.8]) and diabetes duration > 24 years vs 3-10 years (AOR 3.3 [95% CI 1.7-6.4] were significant factors. HbA1c variability was not significant at 12 months.

CONCLUSION

In keeping with the national NDFA data, in our cohort ulcer characteristics, but not HbA1c variability, were the key factors associated with ulcer healing at 12 weeks and 12 months.

Methicillin-resistant Staphylococcus aureus in diabetic and non-diabetic foot infections

To identify the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infection, reinfection and clinical outcomes. Four hundred forty-six patients that were admitted to the hospital with moderate or severe foot infections were retrospectively reviewed. Tissue and bone cultures were obtained from the index hospital admission. Conversion was defined as methicillin susceptible Staphylococcus aureus in the first culture and subsequently MRSA when there was a reinfection. The incidence of MRSA was 7.8% (n = 35), with no significant difference between soft tissue infections (7.7%) and osteomyelitis (8.0%). MRSA incidence was 9.4 times higher in non-diabetics (23.8% vs. 3.2%, p = <0.01). The incidence of reinfection was 40.8% (n = 182). Conversion to MRSA was seen in 2.2% (n = 4) total, occurring in 5.4%. Non-diabetics were 20.1 times more likely to have MRSA reinfection than people with diabetes (28.6% vs. 1.9%, p < 0.001). MRSA patients had a higher proportion of healed wounds (82.4% vs. 69.3%, p = 0.02). There were no differences in other clinical outcomes in MRSA vs. other infections in reinfection (28.6% vs. 24.3%, p = 0.11), amputation (48.6% vs. 52.0%, p = 0.69) or hospitalization (28.6% vs. 42.6, p = 0.11). The incidence of MRSA for the first infection (7.8%), reinfection (6.0%) and conversion to MRSA (2.2%) was low. MRSA was 9.4 times more common in people without diabetes.

Adipose tissue allograft for the management of a pre-ulcerative plantar lesion in a diabetic neuropathic patient

This case describes a minimally invasive implantation of cryopreserved human adipose tissue allograft (CAT) in a diabetic neuropathic patient with a pre-ulcerative plantar lesion. No re-ulceration or adverse events have occurred out to 9 months. CAT provides healthcare providers with an option to manage patients at risk for plantar ulcers.

Prevalence and incidence of peripheral neuropathy, peripheral artery disease, foot disease, and lower extremity amputation in people with diabetes in Ireland; a systematic review protocol

Introduction

Internationally, the prevalence of diabetes is increasing, and with this comes an increase in diabetes related complications. Diabetic foot disease is the most common lower extremity complication in people with diabetes causing 2% of the global disease burden. It, is associated with major morbidity, mortality, and costs to health services. Despite this burden, the incidence and prevalence of diabetic foot disease is unknown in Ireland. This paper presents a protocol for a systematic review to examine the incidence and prevalence of diabetic foot disease in the Irish population.

Methods

A systematic review will be performed using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Pubmed, EMBASE, and Lenus, the Irish Health Research repository, will be searched for publications in any language and without restrictions to date. Title, abstract, and full text screening will be carried out independently by two investigators. Publications reporting on the incidence or prevalence of peripheral neuropathy, peripheral artery disease, ulceration, or amputation in people with diabetes in Ireland, from a defined geographical catchment area of Ireland, will be included. Joanna Briggs Institute (JBI) Critical Appraisal tool will be used to assess included studies methodological quality. Results will be reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines.

Conclusion

The results of this systematic review can be used to inform appropriate stakeholders on the incidence and prevalence of diabetic foot disease in Irish populations, enabling decision making around appropriate use of resources to help prevent, and improve management of this disease.

Systematic review registration

CRD42023472904.

User perceptions of intelligent offloading diabetic footwear

Aims

Adherence to therapeutic footwear is vital for effective diabetic foot ulcer prevention and treatment. Understanding the key adherence factors and potential barriers is important for footwear design and implementation. Our team is creating intelligent offloading footwear to prevent lower extremity amputations in people living with diabetes (PLwD). This exploratory study assessed the ability of the established Unified Theory of Acceptance and Use of Technology (UTAUT) model to predict behavioral intention to use or recommend this intelligent offloading footwear by PLwD, caregivers of PLwD, or medical professionals treating PLwD.

Methods

Online and paper questionnaires were implemented to assess the impact of the UTAUT model factors (performance expectancy, effort expectancy, social influence, facilitating conditions) and psychosocial factors (attitude, anxiety, self-efficacy) on the overall behavioral intention to use the footwear. Furthermore, factors influencing potential acceptance and rejection of the footwear were explored.

Results

Patients (4.0/5) and medical professionals (4.1/5) showed a behavioral intention to "agree" to use or recommend the footwear when it becomes available. Structural equation modeling showed that the UTAUT constructed model may not be the best indicator for behavioral intention here based on a lack of statistical significance. However, the logistic regression modeling showed that the social influence for PLwD (p=0.004) and the attitude toward the footwear for medical professionals (p=0.001) may be the most important when designing and implementing the footwear, though several other factors (performance expectancy, effort expectancy, facilitating conditions, and self-efficacy) were also important for one or both of these populations. Additionally, cost and clinician support were shown to be important factors influencing potential acceptance of the footwear.

Conclusions

The study found promising intention to use the intelligent footwear in the future. This highlights the need to continue future development and implementation of the footwear to incorporate these results, thus improving the likelihood of high adherence of the footwear.

A Machine Learning Model for Prediction of Amputation in Diabetics

BACKGROUND

Diabetic foot ulcer (DFU) and the resulting lower extremity amputation are associated with a poor survival prognosis. The objective of this study is to generate a model for predicting the probability of major amputation in hospitalized patients with DFU.

METHODS

The National Inpatient Sample (NIS) database from 2008 to 2014 was used to select patients with DFU, who were then further divided by major amputation status. International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) and Agency for Healthcare Research and Quality (AHRQ) comorbidity codes were used to compare patient characteristics. For the descriptive statistics, the Student t test, the χ2 test, and the Spearman correlation were utilized. The five most predictive variables were identified. A decision tree model (CTREE) based on conditional inference framework algorithm and a random forest model were used to develop the algorithm.

RESULTS

A total of 326 853 inpatients with DFU were identified, and 5.9% underwent major amputation. The top five contributory variables (all with P < .001) were gangrene (odds ratio [OR] = 11.8, 95% confidence interval [CI] = 11.5-12.2), peripheral vascular disease (OR = 2.9, 95% CI = 2.8-3.0), weight loss (OR = 2.6, 95% CI = 2.5-2.8), systemic infection (OR = 2.5, 95% CI = 2.4-2.53), and osteomyelitis (OR = 1.7, 95% CI = 1.6-1.73). The model performance of the training data was 77.7% (76.1% sensitivity and 79.3% specificity) and of the testing data was 77.8% (76.2% sensitivity and 79.4% specificity). The model was further validated with boosting and random forest models which demonstrated similar performance and area under the curve (AUC) (0.84, 95% CI = 0.83-0.85).

CONCLUSION

Utilizing machine learning methods, we have developed a clinical algorithm that predicts the risk of major lower extremity amputation for inpatients with diabetes with 77.8% accuracy.

Use of computed tomography to identify muscle quality subgroups, spatial mapping, and preliminary relationships to function in those with diabetic peripheral neuropathy

BACKGROUND

Decreased muscle volume and increased muscle-associated adipose tissue (MAAT, sum of intra and inter-muscular adipose tissue) of the foot intrinsic muscle compartment are associated with deformity, decreased function, and increased risk of ulceration and amputation in those with diabetic peripheral neuropathy (DPN).

RESEARCH QUESTION

What is the muscle quality (normal, abnormal muscle, and adipose volumes) of the DPN foot intrinsic compartment, how does it change over time, and is muscle quality related to gait and foot function?

METHODS

Computed tomography was performed on the intrinsic foot muscle compartment of 45 subjects with DPN (mean age: 67.2 ± 6.4 years) at baseline and 3.6 years. Images were processed to obtain volumes of MAAT, highly abnormal, mildly abnormal, and normal muscle. For each category, annual rates of change were calculated. Paired t-tests compared baseline and follow-up. Foot function during gait was assessed using 3D motion analysis and the Foot and Ankle Ability Measure. Correlations between muscle compartment and foot function during gait were analyzed using Pearson's correlations.

RESULTS

Total muscle volume decreased, driven by a loss of normal muscle and mildly abnormal muscle (p<0.05). MAAT and the adipose-muscle ratio increased. At baseline, 51.5% of the compartment was abnormal muscle or MAAT, increasing to 55.0% at follow-up. Decreased total muscle volume correlated with greater midfoot collapse during gait (r = -0.40, p = 0.02). Greater volumes of highly abnormal muscle correlated with a lower FAAM score (r = -0.33, p = 0.03).

SIGNIFICANCE

Muscle volume loss may progress in parallel with MAAT accumulation, impacting contractile performance in individuals with DPN. Only 48.5% of the DPN intrinsic foot muscle compartment consists of normal muscle and greater abnormal muscle is associated with worse foot function. These changes identify an important target for rehabilitative intervention to slow or prevent muscle deterioration and poor foot outcomes.

Diabetic foot disease carries an intrinsic high risk of mortality and other severe outcomes in type 2 diabetes: a propensity score-matched retrospective population-based study

BACKGROUND

To evaluate the association between diabetic foot disease (DFD) and the incidence of fatal and non-fatal events in individuals with type 2 diabetes (T2DM) from primary-care settings.

METHODS

We built a cohort of people with a first DFD episode during 2010-2015, followed up until 2018. These subjects were 1 to 1 propensity score matched to subjects with T2DM without DFD. The incidence of all-cause mortality, the occurrence of new DFD, amputations, cardiovascular diseases, or composite outcome, including all-cause mortality and/or cardiovascular events during the follow-up period, were calculated. A Cox proportional hazard analysis was conducted to evaluate the hazard ratios (HR) for different events.

RESULTS

Overall, 11,117 subjects with T2DM with a first episode of DFD were compared with subjects without DFD. We observed higher incidence rates (IRs) for composite outcome (33.9 vs. 14.5 IR per 100 person-years) and a new DFD episode event (22.2 vs. 1.1 IR per 100 person-years) in the DFD group. Compared to those without DFD, those with a first episode of DFD had a higher HR for all events, with excess rates particularly for amputation and new DFD occurrence (HR: 19.4, 95% CI: 16.7-22.6, HR: 15.1, 95% CI: 13.8-16.5, respectively) was found.

CONCLUSIONS

Although DFD often coexists with other risk factors, it carries an intrinsic high risk of morbidity and mortality in individuals with T2DM. DFD should be regarded as a severe complication already at its onset, as it carries a poor clinical prognosis.

Health literacy and cognitive function in people with diabetic foot ulcer with focus on knowledge, attitude, and practice in relation to foot self-care

Introduction

Preventative foot self-care is vital for avoiding diabetic foot ulcer episodes and lowering the risk of amputations. Yet, it demands high levels of health literacy and cognitive function.

Objective

To investigate health literacy and cognitive function in persons presenting with a diabetic foot ulcer.

Methods

Participants with type 2 diabetes were recruited from the tertiary foot clinic at Steno Diabetes Center North Denmark. The European Health Literacy Survey Questionnaire and Addenbrooke's Cognitive Examination were applied. A semi-structured interview guide was developed to evaluate foot self-care knowledge, attitude, and practice. The qualitative data were analyzed with a deductive approach based on a qualitative thematic analysis model. Subsequently, an integrated analysis of the quantitative and qualitative results was conducted.

Results

The participants (n = 12) had a mean age of 62.6 ± 8.4 years, and 11 were males. The mean diabetes duration was 15.9 ± 8.9 years. Eight participants had a recurrent diabetic foot ulcer. The health literacy level was sufficient in nine participants, and cognitive function was normal in five participants. Three different profiles related to foot self-care (proactive, active, or passive, respectively) were constructed by the final integrated analysis: a proactive profile refers to taking preventative action in concordance with knowledge and attitude, an active profile to taking action in response to a situation, but challenged by conflicting levels of knowledge and attitude, and a passive profile to not taking action.

Conclusion

The study suggests that people presenting with a diabetic foot ulcer have different foot self-care profiles based on person-specific health literacy, cognitive function, and knowledge, attitude, and practice element characteristics, highlighting the need for individualized education and intervention strategy instead of a one-size-fits-all approach.

Peripheral Arterial Disease and the Diabetic Foot Syndrome: Neuropathy Makes the Difference! A Narrative Review

Background: In vascular medicine, peripheral arterial disease (PAD) and diabetic foot syndrome (DFS) are often considered synonymous with respect to the need for revascularization. In PAD patients, clinical symptoms reflect the degree of atherosclerotic disease, since peripheral innervation, including pain sensation, is not usually compromised. In DFS patients, however, symptoms of relevant foot ischemia are often absent and progression of ischemia goes unnoticed owing to diabetic polyneuropathy, the loss of nociception being the main trigger for foot ulcers. This review analyzes the fundamental differences between PAD and DFS against the background of polyneuropathy. Methods: The literature research for the 2014 revision of the German evidence-based S3-PAD-guidelines was extended to 2023. Results: Vascular examination is imperative for both, PAD and DFS. Stage-dependent revascularization is of utmost importance in PAD patients, especially those suffering from critical limb-threatening ischemia (CLTI). Successful therapy of DFS goes further, including infection and metabolic control, wound management, offloading the foot and lifelong prophylaxis in the course of a multidisciplinary treatment concept. Revascularization is not needed in all cases of DFS. Conclusions: There are fundamental differences between PAD and DFS with respect to pathophysiology, the anatomical distribution of arterial occlusive processes, the clinical symptoms, the value of diagnostic tools such as the ankle-brachial index, and classification. Also, therapeutic concepts differ substantially between the two patient populations.

Medication adherence in patients with type 2 diabetes after disability onset: a difference-in-differences analysis using nationwide data

BACKGROUND

Effectively managing the coexistence of both diabetes and disability necessitates substantial effort. Whether disability onset affects adherence to type 2 diabetes medication remains unclear. This study investigated whether disability onset reduces such adherence and whether any reduction varies by disability type.

METHODS

This study used the National Disability Registry and National Health Insurance Research Database from Taiwan to identify patients with type 2 diabetes who subsequently developed a disability from 2013 to 2020; these patients were matched with patients with type 2 diabetes without disability onset during the study period. Type 2 diabetes medication adherence was measured using the medication possession ratio (MPR). A difference-in-differences analysis was performed to determine the effect of disability onset on the MPR.

RESULTS

The difference-in-differences analysis revealed that disability onset caused a reduction of 5.76% in the 1-year MPR (P < 0.001) and 13.21% in the 2-year MPR (P < 0.001). Among all disability types, organ disabilities, multiple disabilities, rare diseases, and a persistent vegetative state exhibited the largest reductions in 2-year MPR.

CONCLUSIONS

Policies aimed at improving medication adherence in individuals with disabilities should consider not only the specific disability type but also the distinct challenges and barriers these patients encounter in maintaining medication adherence.

Subject-specific material properties of the heel pad: An inverse finite element analysis

Individuals with diabetes are at a higher risk of developing foot ulcers. To better understand internal soft tissue loading and potential treatment options, subject-specific finite element (FE) foot models have been used. However, existing models typically lack subject-specific soft tissue material properties and only utilize subject-specific anatomy. Therefore, this study determined subject-specific hindfoot soft tissue material properties from one non-diabetic and one diabetic subject using inverse FE analysis. Each subject underwent cyclic MRI experiments to simulate physiological gait and to obtain compressive force and three-dimensional soft tissue imaging data at 16 phases along the loading-unloading cycles. The FE models consisted of rigid bones and nearly-incompressible first-order Ogden hyperelastic skin, fat, and muscle (resulting in six independent material parameters). Then, calcaneus and loading platen kinematics were computed from imaging data and prescribed to the FE model. Two analyses were performed for each subject. First, the skin, fat, and muscle layers were lumped into a single generic soft tissue material and optimized to the platen force. Second, the skin, fat, and muscle material properties were individually determined by simultaneously optimizing for platen force, muscle vertical displacement, and skin mediolateral bulging. Our results indicated that compared to the individual without diabetes, the individual with diabetes had stiffer generic soft tissue behavior at high strain and that the only substantially stiffer multi-material layer was fat tissue. Thus, we suggest that this protocol serves as a guideline for exploring differences in non-diabetic and diabetic soft tissue material properties in a larger population.

Classification of foot ulcers in people with diabetes: A systematic review

BACKGROUND

Classification and scoring systems can help both clinical management and audit the outcomes of routine care.

AIM

This study aimed to assess published systems used to characterise ulcers in people with diabetes to determine which should be recommended to (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) characterise people with infection and/or peripheral arterial disease, and (d) audit to compare outcomes in different populations. This systematic review is part of the process of developing the 2023 guidelines to classify foot ulcers from the International Working Group on Diabetic Foot.

METHODS

We searched PubMed, Scopus and Web of Science for articles published up to December 2021 which evaluated the association, accuracy or reliability of systems used to classify ulcers in people with diabetes. Published classifications had to have been validated in populations of >80% of people with diabetes and a foot ulcer.

RESULTS

We found 28 systems addressed in 149 studies. Overall, the certainty of the evidence for each classification was low or very low, with 19 (68%) of the classifications being assessed by ≤ 3 studies. The most frequently validated system was the one from Meggitt-Wagner, but the articles validating this system focused mainly on the association between the different grades and amputation. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalisation, limb amputation, mortality, and cost.

CONCLUSION

Despite the limitations, this systematic review provided sufficient evidence to support recommendations on the use of six particular systems in specific clinical scenarios.

Exogenous and endogenous nitric oxide eluting polylactic acid-based nanofibrous scaffolds for enhancing angiogenesis of diabetic wounds

Delayed wound healing is a major complication that diabetic patients suffer from due to high microbial infection susceptibility, high diabetic wound alkalinity, a low lymphangiogenesis rate, and a high inflammation rate, resulting in severe gangrene. Hence, this study aims to develop a multifunctional adhesive nanofibrous patch to promote the wound healing process. Phenytoin, sildenafil citrate, and/or nitric oxide-eluting nanoparticles were incorporated separately within the polylactic acid nanofibrous layer. Polylactic acid was fabricated in the form of highly porous nanofibrous matrices that resemble the natural structure of skin tissues in order to act as scaffolds that help cell migration and proliferation. A polylactic acid nanofibrous layer incorporating phenytoin was designed to stimulate fibroblast proliferation and inhibit inflammation. Another polylactic acid nanofibrous layer was loaded either with nitric oxide-eluting nanoparticles or sildenafil as a pro-angiogenic layer that can supply tissues with nitric oxide gas either exogenously or endogenously, respectively. The developed nanofibrous layers were in-vitro evaluated through different physicochemical, mechanical, and biological approaches. Finally, the efficiency of the prepared single multilayered patch was tested using an in-vivo alloxan-induced diabetic rats' model, which proved that the patches were able to release the incorporated cargos in a controlled manner, enhancing the wound healing process.

Effect of Exercises for Strengthening the Intrinsic Muscles of the Foot and Improving Ankle Mobility on Patients of Diabetic Peripheral Neuropathy

Background and objectives The study aimed to compare the efficacy of standard home care versus structured ankle mobility exercises in enhancing ankle and foot joint range of motion (ROM) among individuals with diabetes mellitus (DM). Additionally, it investigated the impact of foot intrinsic muscle strengthening exercises on hallux grip force in those with Diabetic Peripheral Neuropathy (DN). Materials and methods In a study of 200 patients with Diabetic Neuropathy (DN), selected from 345 screened diabetics with stable glucose levels and routine monitoring at a tertiary care facility, the efficacy of structured exercises versus standard care was evaluated. Participants, aged 40-70 years with mild neuropathic symptoms (neuropathy disability score of 3 to 5), were divided into two groups. Group 1 received standard care per International Diabetic Foot guidelines, while Group 2 performed targeted foot intrinsic muscle strengthening and ankle mobility exercises over eight weeks. The range of motion (ROM) for ankle and first metatarsophalangeal (MTP) joints and hallux grip force were measured, showing significant improvements in Group 2. Analysis was done using IBM SPSS. Results The average age of the individuals in group 1 (n=100) was 53.87±5.42 years, whereas the average age of the subjects in group 2 (n=100) was 54.23±4.69 years. The study included a total of 97 male participants, with 48 in group 1 and 49 in group 2. The groups exhibited homogeneity in terms of age, gender, duration of DM, and BMI (p>,0.05). When comparing the ROM for ankle dorsiflexion between the groups, it was shown that subjects in group 2 had a substantially higher ROM following exercise for both the right (27.97°±5.3° Vs 19.24°±2.54°) and left (28.55°±4.61° Vs 18.22°±1.14°) ankles compared to the patients in group 1 (p<,0.01). Nevertheless, there were statistically insignificant differences (p>,0.05) observed within the groups, both before and after the exercises, for all the variables examined except for right and left ankle dorsiflexion, and right ankle plantarflexion in group 2. Group 2 subjects exhibited a considerably greater hallux grip force compared to group 1 subjects. The mean enhanced paper grip strength for the right and left big toe of group 2 was 44±3.58 N and 43.2±2.62 N respectively. The mean enhanced paper grip force for the right and left big toe of group 1 was 38±3.11 N and 37.92±2.13 N respectively. A statistically highly significant difference was observed for hallux grip force between the groups (p<,0.01). Conclusion The findings of this study suggest that performing the foot intrinsic muscle strengthening and ankle mobility exercises on the foot and ankle joints can potentially enhance ROM and hallux grip force in patient groups with DN.

Development of Cyclic Pressure Offloading Insole for Diabetic Foot Ulcer Prevention

Introduction. The likelihood of developing a diabetic foot ulcer (DFU) during one's lifetime for individuals with diabetes mellitus is around 19% to 34%. Continuous and repetitive loading on soft tissues are the major causative factors for DFU. This paper introduces an air cell array insole designed for cyclically offloading pressure from plantar regions to reduce repetitive stress and loading on foot. Materials and Methods. The insole comprises an air cell array insole and a pneumatic control unit. The interface pressure was evaluated in static and dynamic conditions at 3 different air cell internal pressures (6.9, 10.3, and 13.8 kPa). Plantar interface pressure was measured using a commercial pressure system, and data were analyzed using paired t test. Average interface pressure and peak pressure (PP) were studied to evaluate the functionality and effectiveness of the insole. Results. The analysis of static pressure data revealed that cyclic offloading significantly (p < .05) reduced PP in 4 tested cells corresponding to big toe, metatarsal heads, and heel areas with the maximum mean difference of 12.9 kPa observed in big toe region. Similarly, dynamic pressure data analysis showed that cyclic offloading significantly (p < .05) reduced PP in these areas, with the highest mean PP reduction of 36.98 kPa in the big toe region. Discussion. Results show the insole's capability to reduce plantar pressure through cyclic offloading. Internal pressure of air cells significantly affects the overall pressure reduction and must be chosen based on the user's weight. Conclusion. Results confirm that the insole with offloading capabilities has the potential to reduce the risk of developing DFUs by alleviating the plantar stress during both static and dynamic conditions.

Treatment of clinically uninfected diabetic foot ulcers, with and without antibiotics

OBJECTIVE

Current guidelines do not recommend the use of antibiotics to treat clinically uninfected ulcers. However, physicians continue to prescribe antibiotics for clinically uninfected ulcers with the rationale 'better to be safe than sorry'. Yet, antibiotic resistance is increasing, side-effects are common and treatment costs are rising. Evidence is needed to identify whether antibiotic treatment for clinically uninfected ulcers can be justified or we should stop prescribing them. The aim of this study was to evaluate whether antibiotic treatment in cases of clinically uninfected ulcers improved ulcer healing compared to treatment without antibiotics.

METHOD

Consecutive patients treated in the outpatient clinic for clinically uninfected diabetic foot ulcer both in 2015 and in 2017 were retrospectively analysed. Primary outcome was ulcer healing at one year. Secondary outcomes were limb salvage, freedom from any amputation, amputation-free survival (AFS) and survival.

RESULTS

A total of 102 ulcers of 91 patients were included for final analyses. The non-antibiotics and antibiotics groups both consisted of 51 ulcers. Ulcer healing at one year was 77.3% in the non-antibiotics group and 74.7% in the antibiotics group (p=0.158). No difference was found for limb salvage (93.8% versus 95.9%, respectively; p=0.661), freedom from any amputation (85.6% versus 85.6%, respectively; p=1.000), AFS (85.4% versus 79.1%, respectively; p=0.460) or survival (89.6% versus 83.7%, respectively; p=0.426).

CONCLUSION

In this study, no benefits of antibiotic treatment over non-antibiotic treatment for clinically uninfected ulcers were identified. The findings of this study emphasise the recommendation of current guidelines to not treat clinically uninfected ulcer with antibiotics.

Treatment of diabetic foot with moxibustion: Clinical evidence from meta-analysis

To assess the efficacy of moxibustion for diabetic foot, and compile the findings of randomised clinical trials. China National Knowledge Infrastructure Database, Medicine, WanFang Database, Embase, Chinese Scientific Journal Database and Web of Science were from the establishment to January, 2024 were searched. Randomised controlled trials, which evaluated the effects of moxibustion were included. A total of 12 randomised controlled trials involving 1196 patients were included. According to the pooled results of this meta-analysis, effective rate (relative risk 1.16, 95% confidence intervals, CI [1.11, 1.22]), healing time (mean difference [MD] -6.27, 95% CI [-8.68, -3.86]), wound area (MD 3.46, 95% CI [0.84, 6.09]), and ankle brachial index (MD 0.14, 95% CI [0.03, 0.24]) were statistically significant compared to the control group. This study suggests that moxibustion treatment has the potential for improving symptoms of diabetic foot. However, future in-depth research on the benefits and harms of moxibustion for the diabetic foot is needed before it can be accepted as an evidence-based treatment.

Exploring the mechanical properties of 3D-printed multilayer lattice structures for use in accommodative insoles

Full-contact insoles fabricated from multilayer foams are the standard of care (SoC) for offloading and redistributing high plantar pressures in individuals with diabetes at risk of plantar ulceration and subsequent lower limb amputation. These devices have regional variations in total thickness and layer thickness to create conformity with a patient's foot. Recent work has demonstrated that metamaterials can be tuned to match the mechanical properties of SoC insole foams. However, for devices fabricated using a multilayer lattice structure, having regional variations in total thickness and layer thickness may result in regional differences in mechanical properties that have yet to be investigated. Three lattices, two dual-layer and one uniform-layer lattice structure, designed to model the mechanical properties of SoC insoles, were 3D-printed at three structure/puck thicknesses representing typical regions seen in accommodative insoles. The pucks underwent cyclic compression testing, and the stiffness profiles were assessed. Three pucks at three structure/puck thicknesses fabricated from SoC foams were also tested. Initial evaluations suggested that for the latticed pucks, structure thickness and density inversely impacted puck stiffness. Behaving most like the SoC pucks, a dual-layer lattice that increased in density as structure thickness increased demonstrated consistent stiffness profiles across puck thicknesses. Identifying a lattice with constant mechanical properties at various structure thicknesses may be important to produce a conforming insole that emulates the standard of care from which patient-specific/regional lattice modulations can be made.

The Potential of Autologous Platelet-Rich Plasma Gel for Diabetic Foot Ulcer Care Among Older Adults: A Systematic Review and Meta-Analysis

Introduction

Poorly controlled diabetes mellitus can lead to the development of diabetic foot ulcers (DFU), which is a frequent complication in patients. However, several diabetes management guidelines for older adults do not mention the occurrence of DFUs. Nowadays, Autologous Platelet-Rich Gel (APG) is being used for treating diabetic ulcers. APG is an innovative platelet-derived product with many advantages, such as being low-cost, easy to produce, and readily available materials. Additionally, it does not lead to any rejection reaction.

Objective

This study aims to assess the safety and efficacy of APG as a novel treatment of DFU compared with standard treatment in older adult patients.

Methods

Randomized Controlled Trials (RCTs) were searched using PubMed, Cochrane, Google Scholar, Wiley, and PlosOne. The keywords have been arranged using the Boolean operator, including autologous platelet-rich gel, DFU, and elderly. The data was screened by inclusion and exclusion criteria. The final inclusion study was analyzed and synthesized by tabulation, clusterization, contextual and thematic approach, and assessed for risk of bias using ROB 2.0. Meta-analysis was conducted by using Review Manager 5.4 and the Mantel Haenszel method.

Results

Eight RCTs with 598 patients were eligible for the present analysis. Compared with standard care/conventional treatment, APG could significantly improve the healing wound in patients with diabetic foot ulcers (Relative risk (RR) 1.32, 95% confidence interval (CI) 1.22-1.57, p < 0.0001), shortened the healing time (Mean difference [MD] -16.97 days (95% CI: -32.64 to -1.29; p < 0.00001), shortened the length of hospital stay (MD= -20.11, 95% CI: -38.02, -2.20; p = 0.03), and amputation rate (MD= 0.36, 95% CI: 0.16, 0.84; p = 0.02).

Conclusion

APG treatment can better treat DFU in terms of duration of healing, wound healing, length of hospital stay, and amputation prevention than the standard treatment.

Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population: A Scientific Statement From the American Heart Association

Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population.

Efficacy and pharmacoeconomic advantages of Fufang Huangbai Fluid hydropathic compress in diabetic foot infections: a comparative clinical study with antimicrobial calcium alginate wound dressing

Objective: To compare the intervention effects and pharmacoeconomic advantages of Fufang Huangbai Fluid (FFHB) hydropathic compress versus Antimicrobial Calcium Alginate Wound Dressing (ACAWD) in the treatment of diabetic foot infections (DFI). Methods: Patients with DF who were hospitalized in the peripheral vascular Department of Dongzhimen Hospital of Beijing University of Chinese Medicine from December 2020 to February 2022 and met the inclusion and excluding criteria were allocated into the experimental group and control group through minimization randomization. The experimental group was treated with FFHB hydropathic compress for 2 weeks, while the control group was treated with ACAWD for the same duration. The wound healing of both groups was monitored for 1 month post-discharge. Clinical data from all eligible patients were collected, and differences in various indices between cohorts were analyzed. Results: 22 in the experimental group (including two fell off) and 20 in the control group. After the treatment, the negative rate of wound culture in the experimental group was 30% and that in the control group was 10%, There was no significant difference in the negative rate of wound culture and change trend of minimum inhibitory concentration (MIC) value of drug sensitivity (p > 0.05). The infection control rate of the experimental group was 60%, and that of the control group was 25%. The difference between the two groups was statistically significant (χ2 = 5.013, p = 0.025). The median wound healing rate of the experimental group was 34.4% and that of the control group was 33.3%. There was no significant difference between the two groups (p > 0.05). During the follow-up 1 month later, the wound healing rate in the experimental group was higher, and the difference was statistically significant (p = 0.047). Pharmacoeconomic evaluations indicated that the experimental group had greater cost-effectiveness compared to the control group. Conclusion: In the preliminary study, FFHB demonstrated comparable pathogenic and clinical efficacy to ACAWD in the treatment of mild DF infection, and exhibited superior pharmacoeconomic advantages. With the aid of infection control, the wound healing rate in the FFHB group showed notable improvement. Nevertheless, due to the limited sample size, larger-scale studies are warranted to further validate these findings. Clinical Trial Registration: (https://www.chictr.org.cn/showproj.aspx?proj=66175), identifier (ChiCTR2000041443).

Predicting Union, Osteomyelitis, and Amputation Outcomes of Gustilo IIIC Open Tibial Fractures: A Retrospective Study

OBJECTIVE

Open tibial fractures are frequently encountered in high-energy traumas and can result in significant complications such as nonunion, osteomyelitis, and even amputation. Among open tibial fractures, Gustilo type IIIC cases are particularly challenging due to the concomitant occurrence of neurovascular injuries and soft tissue defects. This study aimed to assess factors that affect union time and complications in Gustilo IIIC tibial fractures.

METHODS

Patients who presented at our center with IIIC open tibial fractures from January 2000 to October 2020 were eligible for this retrospective analysis. Patient demographics, fracture characteristics, and the timing, number, and type of surgical intervention were documented. Outcomes of interest included union time, occurrence of osteomyelitis, and amputation. We performed univariate analyses including chi-squared test, Fischer's exact test, analysis of variance, and Kruskal-Wallis test based on the normality of the data and multivariate analyses including Cox proportional hazards model and logistic regression analyses.

RESULTS

Fifty-eight patients were enrolled and grouped by fracture healing time; eight had timely union (13.8%); 27 had late union (46.6%); eight had delayed union (13.8%); three had nonunion (5.2%); and 12 underwent amputation (20.7%). Nine fractures (15.5%) were complicated by osteomyelitis. Union time was prolonged in cases of triple arterial injury, distal third fractures, multiple trauma with injury severity score (ISS) ≥ 16 points, and increased bone defect length. Additionally, a bone gap >50 mm, diabetes mellitus, low body mass index, and triple arterial injury in the lower leg were significant risk factors for amputation. A time from injury to definitive soft tissue coverage of more than 22 days was the major risk factor for osteomyelitis. A scoring system to predict union time was devised and the predicted probability of union within 2 years was stratified based on this score.

CONCLUSION

IIIC tibial fractures involving the distal third of the tibia, fractures with bone defects, triple arterial injury, and multiple trauma with ISS ≥16 points demonstrated delayed union, and an effective prediction system for union time was introduced in this study. Early soft tissue coverage can reduce the risk of osteomyelitis. Finally, diabetes and severe bone and soft tissue defects pose a higher risk of amputation.

Bypass surgery versus endovascular revascularization for occlusive infrainguinal peripheral artery disease: a meta-analysis of randomized controlled trials for the development of the Italian Guidelines for the treatment of diabetic foot syndrome

To report a review and meta-analysis of all randomized controlled trials (RCTs) comparing bypass surgery (BS) and endovascular treatment (ET) in infrainguinal peripheral arterial disease (PAD) for several endpoints, such as major and minor amputation, major adverse limb events (MALEs), ulcer healing, time to healing, and all-cause mortality to support the development of the Italian Guidelines for the Treatment of Diabetic Foot Syndrome (DFS). A MEDLINE and EMBASE search was performed to identify RCTs, published since 1991 up to June 21, 2023, enrolling patients with lower limb ischemia due to atherosclerotic disease (Rutherford I-VI). Any surgical BS or ET was allowed, irrespective of the approach, route, or graft employed, from iliac to below-the-knee district. Primary endpoint was major amputation rate. Secondary endpoints were amputation-free survival major adverse limb events (MALEs), minor amputation rate, all-cause mortality, ulcer healing rate, time to healing, pain, transcutaneous oxygen pressure (TcPO2) or ankle-brachial index (ABI), quality of life, need for a new procedure, periprocedural serious adverse events (SAE; within 30 days from the procedure), hospital lenght of stay, and operative time. Twelve RCTs were included, one enrolled two separate cohorts of patients, and therefore, the studies included in the analyses were 13. Participants treated with ET had a similar rate of major amputations to participants treated with BS (MH-OR 0.85 [0.60, 1.20], p = 0.36); only one trial reported separately data on patients with diabetes (N = 1), showing no significant difference between ET and BS (MH-OR: 0.67 [0.09, 5.13], p = 0.70). For minor amputation, no between-group significant differences were reported: MH-OR for ET vs BS: 0.83 [0.21, 3.30], p = 0.80). No significant difference in amputation-free survival between the two treatment modalities was identified (MH-OR 0.94 [0.59, 1.49], p = 0.80); only one study reported subgroup analyses on diabetes, with a non-statistical trend toward reduction in favor of ET (MH-OR 0.62 [0.37, 1.04], p = 0.07). No significant difference between treatments was found for all-cause mortality (MH-OR for ET vs BS: 0.98 [0.80, 1.21], p = 0.88). A significantly higher rate of MALE was reported in participants treated with ET (MH-OR: 1.44 [1.05, 1.98], p = 0.03); in diabetes subgroup analysis showed no differences between-group for this outcome (MH-OR: 1.34 [0.76, 2.37], p = 0.30). Operative duration and length of hospital stay were significantly shorter for ET (WMD: - 101.53 [- 127.71, - 75.35] min, p < 0.001, and, - 4.15 [- 5.73, - 2.57] days, p < 0.001 =, respectively). ET was associated with a significantly lower risk of any SAE within 30 days in comparison with BS (MH-OR: 0.60 [0.42, 0.86], p = 0.006). ET was associated with a significantly higher risk of reintervention (MH-OR: 1.57 [1.10, 2.24], p = 0.01). No significant between-group differences were reported for ulcer healing (MH-OR: 1.19 [0.53, 2.69], p = 0.67), although time to healing was shorter (- 1.00 [0.18, 1.82] months, p = 0.02) with BS. No differences were found in terms of quality of life and pain. ABI at the end of the study was reported by 7 studies showing a significant superiority of BS in comparison with ET (WMD: 0.09[0.02; 0.15] points, p = 0.01). The results of this meta-analysis showed no clear superiority of either ET or BS for the treatment of infrainguinal PAD also in diabetic patients. Further high-quality studies are needed, focusing on clinical outcomes, including pre-planned subgroup analyses on specific categories of patients, such as those with diabetes and detailing multidisciplinary team approach and structured follow-up.

Antimicrobial and anti-SARS-CoV-2 activities of smart daclatasvir-chitosan/gelatin nanoparticles-in-PLLA nanofibrous medical textiles; in vitro, and in vivo study

This study aims at the development of electrospun polylactic acid nanofibers (PLLA NFs) incorporating smart daclatasvir-loaded chitosan gelatin nanoparticles to be used as medical textiles. First, smart nanoparticles were prepared through ionic gelation and optimized using Design Expert® software where daclatasvir (DAC), chitosan (CS), and gelatin (GL) amounts were selected to be the independent variables. DAC was used owing to its reported Anti-SARS-CoV-2 activity, CS was chosen due to its antimicrobial activity and GL was used owing to its sensitivity to be hydrolyzed upon exposure to Papain-like protease enzyme (PLpro). The optimum DAC-CS/TAN NPs possessed 109 nm size and 94.44 % entrapment efficiency in addition to sustained drug release for 14 days. Furthermore, upon exposure to PLpro, smart DAC-CS/GL NPs released the whole DAC amount within 3 h. Then, DAC-CS/GL NPs were incorporated within PLLA NFs through electrospinning. Swellability was found to increase gradually reflecting the controlled release of DAC from nanofibers within 3 weeks. Cell viability assessments using human fibroblasts showed that the developed nanofibers possess high biocompatibility. An in-vivo animal model for skin irritation was carried out for two weeks where visual inspection and histopathological investigations showed that neither edema nor erythema were observed.

Early hemodynamics after tibial transverse transport in patients with nonarterial stenosis and arterial stenosis diabetic foot

BACKGROUND

The diagnosis of peripheral arteriopathy in the diabetic foot is complicated by diabetes and its advanced complications. It has been found that diabetic foot can be categorized into arterial stenosis and non-arterial stenosis, both of which have significant differences in hemodynamic characteristics.

AIM

To evaluate the early hemodynamic changes in diabetic foot patients with nonarterial stenosis and arterial stenosis treated by tibial transverse transport (TTT) using high-frequency color Doppler ultrasonography (HFCDU) and a laser Doppler flowmeter.

METHODS

Twenty-five patients with Wagner grades 3-5 diabetic foot ulcers were treated with TTT, and the wound healing time and rate were recorded. Patients were grouped according to the results of preoperative lower-extremity ultrasonography. Cases with ≥ 50% stenosis in any of the femoral, popliteal, posterior tibial, anterior tibial, and peroneal arteries of the affected limb were classified as the arterial stenosis group (n = 16); otherwise, they were classified as the nonarterial stenosis group (n = 9). Before and one month after surgery, HFCDU was used to evaluate the degree of lower limb artery lesions and hemodynamic changes in patients. The degree of femoral-popliteal atherosclerotic stenosis, the degree of vascular stenosis and occlusion of the lower-knee outflow tract, and the degree of medial arterial calcification were scored; the three scores were added together to obtain the total score of lower extremity arteriopathy. PeriScanPIM3, a laser Doppler flowmeter system, was used to detect alterations in plantar microcirculation before and 1 mo after surgery. Wound healing and hemodynamic indices were compared between the two groups.

RESULTS

The wound healing time of the diabetic foot was significantly shorter in the nonarterial stenosis group than in the arterial stenosis group (47.8 ± 13 vs 85.8 ± 26, P < 0.05), and the wound healing rate of both groups was 100%. The preoperative total lower extremity arteriopathy scores were lower in the nonarterial stenosis group than those in the arterial stenosis group (18.89 ± 8.87 vs 24.63 ± 3.52, P < 0.05). The nonarterial stenosis group showed higher preoperative popliteal artery (POA) blood flow than the arterial stenosis group (204.89 ± 80.76 cc/min vs 76.75 ± 48.49 cc/min, P < 0.05). Compared with the baseline (before surgery), the postoperative POA blood flow of the affected limb in the nonarterial stenosis group decreased one month after surgery (134.11 ± 47.84 cc/min vs 204.89 ± 80.76 cc/min, P < 0.05), while that in the arterial stenosis group increased (98.44 ± 30.73 cc/min vs 61.69 ± 21.70 cc/min, P < 0.05). Although the POA blood flow in the arterial stenosis group was obviously improved one month after surgery, it was still lower than that in the nonarterial stenosis group (98.44 ± 30.73 cc/min vs 134.11 ± 47.84 cc/min, P < 0.05). The nonarterial stenosis group had higher preoperative plantar microcirculation than the arterial stenosis group (56.1 ± 9.2 vs 33.2 ± 7.5, P < 0.05); compared with the baseline, the plantar microcirculation in the arterial stenosis group was significantly improved one month after surgery (51.9 ± 7.2, P < 0.05), while that in the nonarterial stenosis group was reduced (35.9 ± 7.2, P < 0.05).

CONCLUSION

Based on preoperative HFCDU findings, diabetic foot patients can be divided into two categories: Those with nonarterial stenosis and those with arterial stenosis, with obvious differences in hemodynamic changes in the early postoperative period between them. In the early stage after TTT, the blood flow volume and velocity and the plantar microcirculation perfusion of the affected limb of the diabetic foot with nonarterial stenosis decreased compared with the baseline, while those of the diabetic foot with arterial stenosis improved significantly compared with the baseline, although both had smoothly healed diabetic foot ulcers.

Foot ulcers in older people with diabetes mellitus: prevention and management

Foot ulcers in a person with diabetes mellitus can be life-changing and threaten the viability of their lower limb. As many as one in three people with diabetes develops a foot ulcer in their lifetime. These foot ulcers are prone to fast-spreading infection and often precede lower-limb amputation. In older people with diabetes, foot ulcers can have significant negative long-term effects in terms of quality of life, morbidity and mortality. Appropriate care is crucial to prevent the development of foot ulcers and to manage them if they develop despite adequate preventive measures. Multidisciplinary team working and robust care pathways are essential. This article outlines the role of nurses in supporting older people with diabetes to maintain optimal foot health, ensuring that they undergo an annual foot assessment, assessing them for foot ulcers and referring them promptly to specialist care when required to avoid amputation.

A 2-Stage Approach in Managing Diabetic Forefoot Ulcers

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Complementary Gene Therapy after Revascularization with the Saphenous Vein in Diabetic Foot Syndrome

Diabetic foot syndrome (DFS) is one of the most serious macroangiopathic complications of diabetes. The primary treatment option is revascularization, but complementary therapies are still being sought. The study group consisted of 18 patients diagnosed with ischemic ulcerative and necrotic lesions in DFS. Patients underwent revascularization procedures and, due to unsatisfactory healing of the lesions, were randomly allocated to two groups: a group in which bicistronic VEGF165/HGF plasmid was administered and a control group in which saline placebo was administered. Before gene therapy administration and after 7, 30, 90, and 180 days, color duplex ultrasonography (CDU) was performed, the ankle-brachial index (ABI) and transcutaneous oxygen pressure (TcPO2) were measured, and DFS changes were described and documented photographically. In the gene therapy group, four out of eight patients (50%) healed their DFS lesions before 12 weeks. During this time, the ABI increased by an average of 0.25 and TcPO2 by 30.4 mmHg. In the control group, healing of the lesions by week 12 occurred in six out of nine patients (66.67%), and the ABI increased by an average of 0.14 and TcPO2 by 27.1 mmHg. One major amputation occurred in each group. Gene therapy may be an attractive option for complementary treatment in DFS.

SARS-CoV-2 Papain-like Protease Responsive ZnO/Daclatasvir-Loaded Chitosan/Gelatin Nanofibers as Smart Antimicrobial Medical Textiles: In Silico, In Vitro and Cell Studies

A significant number of deaths are reported annually worldwide due to microbial and viral infections. The development of protective medical textiles for patients and healthcare professionals has attracted many researchers' attention. Therefore, this study aims to develop smart drug-eluting nanofibrous matrices to be used as a basic material for medical textile fabrication. First, chitosan/gelatin nanofibers were selected as the basic material owing to the wide antimicrobial activity of chitosan and the capability of gelatin to be hydrolyzed in the abundance of the papain-like protease (PLpro) enzyme secreted by SARS-CoV-2. Daclatasvir (DAC), an NS5A inhibitor, was selected as the model drug based on in silico studies where it showed high anti-SARS-CoV-2 potential compared to FDA-approved references. Due to their reported antimicrobial and antiviral activities, ZnO NPs were successfully prepared and incorporated with daclatasvir in chitosan/gelatin nanofibrous matrices through electrospinning. Afterward, an in vitro release study in a simulated buffer revealed the controlled release of DAC over 21 days from the nanofibers compared to only 6 h for free DAC. On the other hand, the abundance of PLpro induced the complete release of DAC from the nanofibers in only 4-8 h. Finally, the nanofibers demonstrated a wide antimicrobial activity against S. aureus, E. coli, and C. albicans.

Socioeconomic Deprivation as a Predictor of Lower Limb Amputation in Diabetic Foot Disease

Objective The prevalence of diabetes and its complications are on the rise worldwide. This is particularly prevalent in low- and middle-income countries. The Index of Multiple Deprivation (IMD) is a measure of relative social deprivation. This index classifies England into small subsets called lower layer super output areas (LSOAs) and then ranks these LSOAs into deciles from the most deprived to the least deprived area. We used this to analyse the relationship between deprivation and outcomes in diabetic foot disease (DFD). Methods We evaluated patients admitted to our multidisciplinary unit with DFD over a five-year period. Their postal codes were used to classify these patients into IMD deciles with decile 1 representing the 10% of most deprived LSOAs and decile 10 the least deprived areas in the country. We used this classification to analyse the relationship between deprivation and its influence on surgical outcomes and lower limb amputation. We specifically compared those falling in the top five against the bottom five deciles. Results Our cohort consisted of 70 patients with diabetes who had surgery on their diabetic foot. Of this cohort, 33 (47%) of these underwent amputation. The majority of these procedures were minor amputations conducted on the forefoot (75.6%) and there were no below knee amputations. Of those requiring an amputation, 27 patients (81.8%) had an IMD decile of 5 or below, and only six (18.2%) patients had above 5. Conclusion Our study shows that the likelihood of amputations related to diabetic foot disease is inversely proportional to the index of multiple deprivation.

Intelligent plantar pressure offloading for the prevention of diabetic foot ulcers and amputations

The high prevalence of lower extremity ulceration and amputation in people with diabetes is strongly linked to difficulties in achieving and maintaining a reduction of high plantar pressures (PPs) which remains an important risk factor. The effectiveness of current offloading footwear is opposed in part by poor patient adherence to these interventions which have an impact on everyday living activities of patients. Moreover, the offloading devices currently available utilize primarily passive techniques, whereas PP distribution is a dynamically changing process with frequent shifts of high PP areas under different areas of the foot. Thus, there is a need for pressure offloading footwear capable of regularly and autonomously adapting to PPs of people with diabetes. The aim of this article is to summarize the concepts of intelligent pressure offloading footwear under development which will regulate PPs in people with diabetes to prevent and treat diabetic foot ulcers. Our team is creating this intelligent footwear with an auto-contouring insole which will continuously read PPs and adapt its shape in the forefoot and heel regions to redistribute high PP areas. The PP-redistribution process is to be performed consistently while the footwear is being worn. To improve adherence, the footwear is designed to resemble a conventional shoe worn by patients in everyday life. Preliminary pressure offloading and user perceptions assessments in people without and with diabetes, respectively, exhibit encouraging results for the future directions of the footwear. Overall, this intelligent footwear is designed to prevent and treat diabetic foot ulcers while enhancing patient usability for the ultimate prevention of lower limb amputations.