Total contact casting of the diabetic foot in daily practice: a prospective follow-up study

Outcomes of Flap Reconstruction for Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis of Clinical Studies

BACKGROUND

People with diabetic foot ulcers (DFUs) are at risk of major amputation, which is associated with a high mortality rate (exceeding 50% at 5 years) and reduced quality of life. The authors hypothesized that flap reconstruction of DFUs improves patient outcomes in comparison with standard treatment modalities, including major amputation.

METHODS

MEDLINE, Embase, the Cochrane Library, and gray literature were searched on February 9, 2022. Comparative and single-arm studies reporting outcomes of DFUs treated with local, regional, or free flaps that included function, limb loss, mortality rates, and flap failure rates were included. Risk of bias was assessed, and meta-analysis of proportions was performed.

RESULTS

A total of 3878 records were retrieved, of which 45 met the inclusion criteria, including the records of 1681 patients who underwent flap reconstruction of DFUs. Free flaps were most commonly performed ( n = 1257 [72%]). Only one study used a verified functional outcome measure. At 12 months, the mortality rate was 6.35% (95% CI, 3.89% to 10.20%), the limb loss rate was 11.39% (95% CI, 7.02% to 17.96%), and the free flap failure rate was 9.95% (95% CI, 8.19% to 12.05%). All studies were at high risk of bias. A comparative meta-analysis of interventions was not performed because of study method and outcome heterogeneity.

CONCLUSIONS

There is short-term evidence that flap reconstruction (including microsurgical transfer) has low mortality, limb loss, and flap failure rates. However, there are limited high-quality comparative studies, and uncertainty remains regarding the outcome of DFU flap reconstruction in comparison to other treatments.

Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot

The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.

Evidence-based interventions for identifying candidate quality indicators to assess quality of care in diabetic foot clinics: a scoping review

BACKGROUND

Foot ulcers in people with diabetes are a serious complication requiring a complex management and have a high societal impact. Quality monitoring systems to optimize diabetic foot care exist, but a formal and more evidence-based approach to develop quality indicators (QIs) is lacking. We aimed to identify a set of candidate indicators for diabetic foot care by adopting an evidence-based methodology.

METHODS

A systematic search was conducted across four academic databases: PubMed, Embase CINAHL and Cochrane Library. Studies that reported evidence-based interventions related to organization or delivery of diabetic foot care were searched. Data from the eligible studies were summarized and used to formulate process and structure indicators. The evidence for each candidate QI was described in a methodical and transparent manner. The review process was reported according to the "Preferred Reported Items for Systematic reviews and Meta-Analysis" (PRISMA) statements and its extension for scoping reviews.

RESULTS

In total, 981 full-text articles were screened, and 322 clinical studies were used to formulate 42 candidate QIs.

CONCLUSIONS

An evidence-based approach could be used to select candidate indicators for diabetic foot ulcer care, relating to the following domains: wound healing interventions, peripheral artery disease, offloading, secondary prevention, and interventions related to organization of care. In a further step, the feasibility of the identified set of indicators will be assessed by a multidisciplinary panel of diabetic foot care stakeholders.

Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis

BACKGROUND

Offloading treatment is crucial to heal diabetes-related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU.

METHODS

We searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight-bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost-effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta-analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed.

RESULTS

From 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non-controlled), 35 meta-analyses performed, and 128 evidence statements developed. We found non-removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09-1.41; N = 14, n = 1083), and may increase adherence, cost-effectiveness and decrease infections, but may increase new lesions. Removable knee-high offloading devices may make little difference to ulcers healed compared to removable ankle-high offloading devices (RR 1.00, 0.86-1.16; N = 6, n = 439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89-2.18; N = 5, n = 235) and cost-effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05-5.59; N = 1, n = 16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97-1.27; N = 1, n = 64) and sustained healing compared to devices alone, but likely increase new heel ulcers.

CONCLUSIONS

Non-removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non-surgical offloading interventions to heal most plantar DFU. However, all these interventions have low-to-moderate certainty of evidence supporting their outcomes and more high-quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.

Graded stiffness offloading insoles better redistribute heel plantar pressure to protect the diabetic neuropathic foot

BACKGROUND

Diabetic heel ulceration is a common, detrimental, and costly complication of diabetes. This study investigates a novel "graded-stiffness" offloading method, which consists of a heel support with increasing levels of stiffness materials to better redistribute plantar pressure for heel ulcer prevention and treatment.

RESEARCH QUESTION

Is the novel "graded-stiffness" solution better able to redistribute heel pressure and reduce focal stress concentration areas of the heel?

METHODS

Twenty healthy young men walked with four, 3D-printed, insole configurations. The configurations included the "graded-stiffness" insoles with and without an offloading hole under the heel tissue at risk for ulcerations and two conventional offloading supports of flat insoles with no offloading and simple holed offloading insoles. In-shoe plantar pressure was measured using the Pedar-X system. Peak pressure and pressure dose were measured at three heel regions: offloaded region, perimeter of offloaded region, and periphery region.

RESULTS

The simple offloading configuration reduced pressure at the offloaded region; however, pressure at the perimeter of the offloading region significantly increased. With respect to ANOVA, the "graded-stiffness" offloading configurations were more effective than existing tested solutions in reducing and redistributing heel peak pressure and pressure dose, considering all heel regions.

SIGNIFICANCE

The "graded-stiffness" offloading solution demonstrated a novel flexible and customized solution that can be manufactured on-demand through a precise selection of the graded-stiffness offloading location and material properties to fit the shape and size of the ulcer. This study is a follow-up in-vivo pilot study, in a healthy population group, to our previous computation modeling work that reported the efficiency of the "graded-stiffness" configuration, and which emphasizes its potential for streamlining and optimizing the prevention and treatment of diabetic heel ulcers.

A novel graded-stiffness footwear device for heel ulcer prevention and treatment: a finite element-based study

Diabetic heel ulceration is a serious, destructive, and costly complication of diabetes. In this study, a novel "graded-stiffness" offloading method was proposed. This method consists of heel support with multi-increasing levels of stiffness materials, to prevent and treat heel ulcers. A three-dimensional finite element model of the heel was used to evaluate the novel "graded-stiffness" orthotic device compared to two existing solutions: (1) an insole with a hole under the active ulcer and (2) an insole with a hole filled with a soft material (elastic modulus of 15 kPa). Volumetric exposure evaluation of internal tissues to stress was performed at two volume-of-interests: (1) the area of the heel soft tissues typically at high risk for ulceration, and (2) the soft tissues surrounding the high-risk area. The models predict that the "graded-stiffness" offloading solution is more effective than existing solutions in distributing and reducing heel internal loads, considering both volume-of-interests. Comparing different material gradient combinations for the offloading support reveals considerable variation of the heel stress distribution. In clinical practice, the "graded-stiffness" technological solution enables to form an adaptable and flexible system that can be customized to a specific patient, through adequate selection of the offloading materials, to fit the shape and size of the ulcer. This solution can be made as an off-the-shelf product or alternatively, be manufactured by-demand using 3D printing tools. The proposed novel practical offloading solution has the potential for streamlining and optimizing the prevention and treatment of diabetic heel ulcers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Stress-Reducing Psychological Interventions as Adjuvant Therapies for Diabetic Chronic Wounds

BACKGROUND

Diabetic foot ulcers (DFUs) are a major complication of diabetes mellitus and a leading cause of lower limb amputation. Interventions to reduce psychological stress may have the potential to improve self-care and greatly reduce the morbidity and mortality associated with DFU. This review is focused on the consequences of psychological stress in wound healing and reflects on the effects of currently used psychological stress-reducing interventions in patients with DFU, proposing new applications for currently used stress-reduction interventions.

RESULTS

Stress is a natural and fundamental survival mechanism that becomes harmful when chronic. DFU is associated with high levels of anxiety and chronic psychological stress. Chronic stressinduced cortisol and adrenaline release impair wound healing, independently of the stressor. Psychological stress-reducing interventions, such as relaxation with guided imagery, biofeedback-assisted relaxation, mindfulness-based strategies, and hypnosis, can lead to a reduction in perceived stress and improve wound healing by reducing wound inflammation and pain while improving glycemic control. All stress reduction interventions also lead to pain relief and improved patient's quality of life.

CONCLUSION

Psychological stress-reducing interventions are promising adjuvant therapies for DFU. Their clinical application can improve self-care by tackling patient's expectations, anxieties, and fears. They can also help patients manage stress and pain while reducing wound inflammation and improving wound healing.

Characteristics of new patient referrals to specialised diabetic foot units across Europe and factors influencing delays

OBJECTIVE

Foot ulcers are a common complication of diabetes and are associated with an increase in lower limb amputation and death. Early referral to a specialised unit is recommended. The aim of this study was to assess the characteristics of new-patient referrals to specialised diabetes foot care units across Europe and to determine the factors involved in delayed referral.

METHOD

In this prospective observational study, consecutive patients with a new foot ulcer presenting to nine diabetic foot centres in five European countries (France, Germany, Italy, Spain and the UK) were included.

RESULTS

Some 25% of the 332 patients included had presented with a foot ulcer >3 months before referral to the participating foot clinic. Compared with patients referred earlier, patients with a long time to referral (>3 months) were older (p=0.006) and had a less severe wound according to Infectious Diseases Society of America (IDSA) classification (p=0.003) and University of Texas classification (grade D=infection + peripheral artery disease, p=0.004).

CONCLUSION

The proportion of patients with a diabetic foot ulcer (DFU) referred to a specialised unit >3 months after the beginning of the ulcer remained high throughout Europe. Patients with severe DFU were, however, referred more quickly by front line health professionals. Primary care professionals need to be made aware of the importance of early referral to a specialised unit in order to improve the management of foot disease in patients with diabetes.

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Patients with Diabetes Complicated by Peripheral Artery Disease: the Current State of Knowledge on Physiotherapy Interventions

Diabetes mellitus (DM) is one of the major public health problems that account for morbidity, mortality, and disability worldwide. The presence of DM increases the risk of peripheral artery disease (PAD), as well as accelerates its course, making these patients more susceptible to ischemic events and impaired functional status. Unfortunately, alternative treatments for vascular complications in diabetes are poorly researched. Physiotherapy (kinesitherapy combined with different physical therapy agents) in individuals with DM and coexisting PAD may offer an important complementary therapy alternative. Early therapeutic measures can significantly improve patient outcomes, reduce cardiovascular risk, and improve daily life quality. The article provides an update on the current state of knowledge on physiotherapy interventions in the course of DM in patients with coexisting PAD.

Comparison of a new versus standard removable offloading device in patients with neuropathic diabetic foot ulcers: a French national, multicentre, open-label randomized, controlled trial

INTRODUCTION

The offloading is crucial to heal neuropathic diabetic foot ulcer (DFU). Removable offloading are the most used devices. Orthèse diabète is a new customized removable knee-high offloading device immobilizing foot and ankle joints, with some specific and innovative features that may improve offloading. We aimed to evaluate the efficiency of this device in DFU healing.

RESEARCH, DESIGN AND METHODS

The evaluation of Offloading using a new removable ORTHOsis in DIABetic foot study is a French multicenter (13 centers) randomized controlled trial with blinded end points evaluation. Adults with neuropathic DFU were randomly assigned to either Orthèse Diabète (experimental device), or any type of conventional (usually used in France) removable offloading devices (control group). The primary outcome was the 3-month proportion of patients with fully healed DFU.

RESULTS

Among 112 randomized patients (men 78%, age 62±10 years), the primary outcome occurred in 19 (33%) participants using conventional device vs 19 (35%) Orthèse Diabète users (p=0.79). Study groups were also comparable in terms of prespecified secondary end points including occurrence of new DFU (25% vs 27% in conventional and experimental groups), ipsilateral lower-limb amputation (4% vs 10%) or infectious complications (14% vs 13%) (p>0.05 for all). Adverse events were comparable between groups, including 4 deaths unrelated to study allocation (1 sudden death, 2 ventricular arrhythmias and 1 pancreatic cancer). Adverse events believed to be related to the device were higher in the Orthèse Diabète group than in the control group (15% vs 4%). Orthèse Diabète was less frequently worn than conventional devices (46% vs 66%, p=0.04).

CONCLUSIONS

Orthèse Diabète, a new removable offloading orthosis immobilizing foot and ankle joints did not show superiority compared with conventional removable devices in neuropathic DFU healing and cannot be recommended to heal DFU.

TRIAL REGISTRATION NUMBER

NCT01956162.

Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review

BACKGROUND

Offloading interventions are commonly used in clinical practice to heal foot ulcers. The aim of this updated systematic review is to investigate the effectiveness of offloading interventions to heal diabetic foot ulcers.

METHODS

We updated our previous systematic review search of PubMed, EMBASE, and Cochrane databases to also include original studies published between July 29, 2014 and August 13, 2018 relating to four offloading intervention categories in populations with diabetic foot ulcers: (a) offloading devices, (b) footwear, (c) other offloading techniques, and (d) surgical offloading techniques. Outcomes included ulcer healing, plantar pressure, ambulatory activity, adherence, adverse events, patient-reported measures, and cost-effectiveness. Included controlled studies were assessed for methodological quality and had key data extracted into evidence and risk of bias tables. Included non-controlled studies were summarised on a narrative basis.

RESULTS

We identified 41 studies from our updated search for a total of 165 included studies. Six included studies were meta-analyses, 26 randomised controlled trials (RCTs), 13 other controlled studies, and 120 non-controlled studies. Five meta-analyses and 12 RCTs provided high-quality evidence for non-removable knee-high offloading devices being more effective than removable offloading devices and therapeutic footwear for healing plantar forefoot and midfoot ulcers. Total contact casts (TCCs) and non-removable knee-high walkers were shown to be equally effective. Moderate-quality evidence exists for removable knee-high and ankle-high offloading devices being equally effective in healing, but knee-high devices have a larger effect on reducing plantar pressure and ambulatory activity. Low-quality evidence exists for the use of felted foam and surgical offloading to promote healing of plantar forefoot and midfoot ulcers. Very limited evidence exists for the efficacy of any offloading intervention for healing plantar heel ulcers, non-plantar ulcers, and neuropathic ulcers with infection or ischemia.

CONCLUSION

Strong evidence supports the use of non-removable knee-high offloading devices (either TCC or non-removable walker) as the first-choice offloading intervention for healing plantar neuropathic forefoot and midfoot ulcers. Removable offloading devices, either knee-high or ankle-high, are preferred as second choice over other offloading interventions. The evidence bases to support any other offloading intervention is still weak and more high-quality controlled studies are needed in these areas.

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.

[Differentiated treatment of patients with diabetic foot syndrome at the stage of specialized surgical care]

AIM

To assess 1-year results of differentiated treatment of patients with diabetic foot syndrome (DFS) who were included into 3-year register of diabetic foot outpatient practice (DFOP).

MATERIAL AND METHODS

It was performed retrospective analysis of 570 patients with DFS (2015-2017): group I - neuropathic form (n=285), group II - neuroischemic form (n=285). Patients were classified according to Texas grade. Group I - 107 (37.5%) patients (BI-III); 91 (31.9%) patients (AII+BII-III). Diabetic osteoarthropathy was diagnosed in 97 (34.0%) cases. Group II included 113 (45.2%) patients with DI-III and 171 (60.0%) patients with CII-II+DII-III. 308 patients received combined outpatient treatment (including limb off-loading in 88%), 195 patients - in-hospital surgical treatment (including endovascular procedures - 52), 67 patients - treatment at the place of residence. Postoperative follow-up was in diabetic foot outpatient practice. Statistical analysis of data was performed by using of Biostat software package.

RESULTS

In group I 1-year results are unknown in 76 (26.7%) patients. Epitheliazation was noted in 101 (35.4%) cases, persistent diabetic ulcer - in 27 (12.9%), small amputations - 16 (7.7%), high amputations - 2 (0.95%). In group II results are unknown in 29 (10.2%) patients. Epitheliazation occurred in 121 (47.3%) cases, persistent diabetic ulcer - 53 (20.7%), small amputations - 47 (18.4%), high amputations - in 35 (13.7%) cases.

CONCLUSION

DFOP is a key organizational unit of specialized medical care for patients with DFS. Regular follow-up of patients in DFOP and combined treatment at the stage of specialized surgical care allows to preserve limb in 99% of patients with neuropathic foot and in 86.3% of patients with neuroischemic foot.

An integrative review of therapeutic footwear for neuropathic foot due to diabetes mellitus

BACKGROUND

Therapeutic footwear is built on a model of patient's foot, for people with diabetes suffering with neuropathy. Can the footwear helps to improve plantar pressure in neuropathic foot? This study focussed on available data on therapeutic footwear as an intervention for improving and offloading plantar pressure in neuropathic diabetic foot.

METHODS

Relevant scientific literature in PubMed, Medline and Google Scholar published between 2000 and 2017 were searched. The keywords searched were therapeutic footwear, plantar pressure, neuropathic foot, rocker sole, ulcer healing and offloading of plantar pressure. Articles on randomized controlled trials, observational, cohort, feasibility and factorial studies were reviewed.

RESULTS

One hundred and twenty five (125) articles were identified. The article comprised of 6 randomized controlled trials, 2 observational, 1 cohort, 1 feasibility and 1 factorial study met the inclusion criteria and were critiqued with a total enrolment of 1380 study subjects.

CONCLUSIONS

The review of the collated literature demonstrated that, therapeutic footwear can improve the healing of neuropathic diabetic foot ulcer by redistributing plantar pressure. However, the efficacy of therapeutic footwear requires the inclusion of technical features that should not be compromised from the design to the production of the footwear.

A Narrative Review of the Benefits and Risks of Total Contact Casts in the Management of Diabetic Foot Ulcers

Total contact casts are recognized as the gold standard treatment for neuropathic plantar diabetic foot ulceration, endorsed by all national and international consensus papers. Despite this, research has shown that there is a dichotomy between the existing evidence which supports the use of total contact casts in the management of diabetic foot ulcers and its use in clinical practice. This article aims to highlight the benefits, risks, and barriers associated with total contact cast use in the management of diabetic foot ulcers in the clinical setting, with an emphasis on existing research carried out in this field to encourage change in clinical practice and utilization of this effective treatment modality.

Evaluation of the effectiveness and cost-effectiveness of lightweight fibreglass heel casts in the management of ulcers of the heel in diabetes: a randomised controlled trial

BACKGROUND

Ulcers of the foot in people with diabetes mellitus are slow to heal and result in considerable cost and patient suffering. The prognosis is worst for ulcers of the heel.

OBJECTIVE

To assess both the clinical effectiveness and the cost-effectiveness of lightweight fibreglass casts in the management of heel ulcers.

DESIGN

A pragmatic, multicentre, parallel, observer-blinded randomised controlled trial. A central randomisation centre used a computer-generated random number sequence to allocate participants to groups.

SETTING

Thirty-five specialist diabetic foot secondary care centres in the UK. Those recruited were aged ≥ 18 years and had diabetes mellitus complicated by ulcers of the heel of grades 2-4 on the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel scale.

PARTICIPANTS

In total, 509 participants [68% male, 15% with type 1 diabetes mellitus, mean age 67.5 years (standard deviation 12.4 years)] were randomised 1 : 1 to the intervention (n = 256) or the control (n = 253) arm. The primary outcome data were available for 425 participants (212 from the intervention arm and 213 from the control arm) and exceeded the total required; attrition was 16.5%. The median ulcer area at baseline was 275 mm² [interquartile range (IQR) 104-683 mm²] in the intervention group and 206 mm² (IQR 77-649 mm²) in the control group. There were no differences between the two groups at baseline in any parameter, neither in relation to the participant nor in relation to their ulcer.

INTERVENTIONS

The intervention group received usual care supplemented by the addition of an individually moulded, lightweight, fibreglass heel cast. The control group received usual care alone. The intervention phase continued either until the participant's ulcer had healed (maintained for 28 days) or for 24 weeks, whichever occurred first. During this intervention phase, the participants were reviewed every 2 weeks, and the fibreglass casts were replaced when they were no longer usable.

MAIN OUTCOME MEASURES

The primary outcome measure was ulcer healing (confirmed by a blinded observer and maintained for 4 weeks) within 24 weeks. Other outcome measures included the time taken for the ulcer to heal, the percentage reduction in the cross-sectional area, the reduction in local pain, amputation, survival and health economic analysis. The study was powered to define a difference in healing of 15% (55% intervention vs. 40% control).

RESULTS

Forty-four per cent (n = 94) of the intervention group healed within 24 weeks, compared with 37% (n = 80) of the control participants (odds ratio 1.42, 95% confidence interval 0.95 to 2.14; p = 0.088), using an intention-to-treat analysis. No differences were observed between the two groups for any secondary outcome.

LIMITATIONS

Although the component items of care were standardised, because this was a pragmatic trial, usual care was not uniform. There was some evidence of a small excess of adverse events in the intervention group; however, non-blinded observers documented these events. There was no excess of adverse device effects.

CONCLUSIONS

There may be a small increase in healing with the use of a heel cast, but the estimate was not sufficiently precise to provide strong evidence of an effect. There was no evidence of any subgroup in which the intervention appeared to be particularly effective. A health economic analysis suggested that it is unlikely that the intervention represents good value for money. The provision of a lightweight heel cast may be of benefit to some individuals, but we have found no evidence to justify the routine adoption of this in clinical practice.

FUTURE WORK

It is unlikely that further study of this intervention will have an impact on usual clinical care, and so future efforts should be directed towards other interventions designed to improve the healing of ulcers in this population.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN62524796.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 34. See the NIHR Journals Library website for further project information.

The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years

BACKGROUND

Close contact casting (CCC) may offer an alternative to open reduction and internal fixation (ORIF) surgery for unstable ankle fractures in older adults.

OBJECTIVES

We aimed to (1) determine if CCC for unstable ankle fractures in adults aged over 60 years resulted in equivalent clinical outcome compared with ORIF, (2) estimate cost-effectiveness to the NHS and society and (3) explore participant experiences.

DESIGN

A pragmatic, multicentre, equivalence randomised controlled trial incorporating health economic evaluation and qualitative study.

SETTING

Trauma and orthopaedic departments of 24 NHS hospitals.

PARTICIPANTS

Adults aged over 60 years with unstable ankle fracture. Those with serious limb or concomitant disease or substantial cognitive impairment were excluded.

INTERVENTIONS

CCC was conducted under anaesthetic in theatre by surgeons who attended training. ORIF was as per local practice. Participants were randomised in 1 : 1 allocation via remote telephone randomisation. Sequence generation was by random block size, with stratification by centre and fracture pattern.

MAIN OUTCOME MEASURES

Follow-up was conducted at 6 weeks and, by blinded outcome assessors, at 6 months after randomisation. The primary outcome was the Olerud-Molander Ankle Score (OMAS), a patient-reported assessment of ankle function, at 6 months. Secondary outcomes were quality of life (as measured by the European Quality of Life 5-Dimensions, Short Form questionnaire-12 items), pain, ankle range of motion and mobility (as measured by the timed up and go test), patient satisfaction and radiological measures. In accordance with equivalence trial US Food and Drug Administration guidance, primary analysis was per protocol.

RESULTS

We recruited 620 participants, 95 from the pilot and 525 from the multicentre phase, between June 2010 and November 2013. The majority of participants, 579 out of 620 (93%), received the allocated treatment; 52 out of 275 (19%) who received CCC later converted to ORIF because of loss of fracture reduction. CCC resulted in equivalent ankle function compared with ORIF at 6 months {OMAS 64.5 points [standard deviation (SD) 22.4 points] vs. OMAS 66.0 points (SD 21.1 points); mean difference -0.65 points, 95% confidence interval (CI) -3.98 to 2.68 points; standardised effect size -0.04, 95% CI -0.23 to 0.15}. There were no differences in quality of life, ankle motion, pain, mobility and patient satisfaction. Infection and/or wound problems were more common with ORIF [29/298 (10%) vs. 4/275 (1%)], as were additional operating theatre procedures [17/298 (6%) vs. 3/275 (1%)]. Malunion was more common with CCC [38/249 (15%) vs. 8/274 (3%); p < 0.001]. Malleolar non-union was lower in the ORIF group [lateral: 0/274 (0%) vs. 8/248 (3%); p = 0.002; medial: 3/274 (1%) vs. 18/248 (7%); p < 0.001]. During the trial, CCC showed modest mean cost savings [NHS mean difference -£644 (95% CI -£1390 to £76); society mean difference -£683 (95% CI -£1851 to £536)]. Estimates showed some imprecision. Incremental quality-adjusted life-years following CCC were no different from ORIF. Over common willingness-to-pay thresholds, the probability that CCC was cost-effective was very high (> 95% from NHS perspective and 85% from societal perspective). Experiences of treatments were similar; both groups endured the impact of fracture, uncertainty regarding future function and the need for further interventions.

LIMITATIONS

Assessors at 6 weeks were necessarily not blinded. The learning-effect analysis was inconclusive because of limited CCC applications per surgeon.

CONCLUSIONS

CCC provides a clinically equivalent outcome to ORIF at reduced cost to the NHS and to society at 6 months.

FUTURE WORK

Longer-term follow-up of trial participants is under way to address concerns over potential later complications or additional procedures and their potential to impact on ankle function. Further study of the patient factors, radiological fracture patterns and outcomes, treatment responses and prognosis would also contribute to understanding the treatment pathway.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN04180738.

FUNDING

The National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 75. See the NIHR Journals Library website for further project information. This report was developed in association with the National Institute for Health Research Oxford Biomedical Research Unit funding scheme. The pilot phase was funded by the AO Research Foundation.

The efficacy of removable devices to offload and heal neuropathic plantar forefoot ulcers in people with diabetes: a single-blinded multicentre randomised controlled trial

Non-removable offloading is the 'gold standard' treatment for neuropathic diabetic plantar forefoot ulcers. However, removable offloading is the common 'standard of care'. We compared three removable offloading devices for ulcer healing efficacy. In this multicentre, randomised controlled trial, 60 persons with neuropathic diabetic plantar forefoot ulcers were randomly assigned to wear a custom-made knee-high cast [BTCC (bivalved TCC)], custom-made ankle-high cast shoe or a prefabricated ankle-high forefoot-offloading shoe (FOS). Primary outcome was healing at 12 weeks. Dynamic plantar pressures, daily stride count and treatment adherence were assessed on a randomly selected subset (n = 35). According to intention-to-treat analysis, 58% of patients healed with BTCC [OR 0·77 (95% CI 0·41-1·45) versus FOS], 60% with cast shoe [OR 0·81 (95% CI 0·44-1·49) versus FOS] and 70% with FOS (P = 0·70). Mean ± SD peak pressure in kPa at the ulcer site was 81 ± 55 for BTCC, 176 ± 80 for cast shoe and 107 ± 52 for FOS (P = 0·005); stride count was 4150 ± 1626, 3514 ± 1380 and 4447 ± 3190, respectively (P = 0·71); percentage of 2-week intervals that patients wore the device <50% of time was 17·3%, 5·2% and 4·9%, respectively. Non-significant differences in healing efficacy between the three devices suggest that, when non-removable offloading is contraindicated or not available, each can be used for plantar forefoot ulcer offloading. Efficacy is lower than previously found for non-removable offloading maybe because suboptimal adherence and high stride count expose the patient to high repetitive stresses. These factors should be carefully considered in decision making regarding ulcer treatment.

Outcomes Achieved With Use of a Prefabricated Roll-On Total Contact Cast

BACKGROUND

The total contact cast (TCC) is considered the gold standard for offloading of plantar diabetic foot ulcerations, yet its use remains suboptimal for a variety of reasons. Prefabricated TCC systems have been developed to help enhance TCC use. The primary objective of this study was to determine if healing rates obtained with use of a prefabricated roll-on TCC were similar to those reported with conventional TCC use. Secondary outcomes measured were the incidence of iatrogenic ulceration, amputation, and recurrent ulceration, and patient tolerance of the device.

METHODS

A retrospective chart review was performed on all patients in whom TCC was used for treatment of an ulceration at our institution from April 2013 to December 2016. Seventy patients (132 ulcerations) were identified.

RESULTS

An 85.6% healing rate was achieved. Five subjects (7.1%) sustained 11 iatrogenic ulcerations. All resolved with local treatment and continued casting. Thirteen subjects (18.6%) underwent amputation. No amputation occurred because of TCC application technique or use. Fifteen ulcerations (12 subjects, 17.1%) recurred. Greater than 70% resolved with re-initiation of TCC use. Forty-three subjects (61.4%) tolerated use of the prefabricated roll-on TCC.

CONCLUSION

Similar healing rates and reduced rates of iatrogenic ulceration, amputation, and recurrent ulceration were attained with use of a prefabricated roll-on TCC. These results, good patient tolerance, and the reduced administrative and clinical time related to supply acquisition, training, and proper application supports use of this device as a viable alternative to a conventional TCC for treatment of plantar neuropathic foot ulcerations.

LEVEL OF EVIDENCE

Level IV, case series.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Wound healing and treating wounds: Chronic wound care and management

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

Diabetic Foot Ulcers: The Importance of Patient Comorbidity Recognition and Total Contact Casting in Successful Wound Care

Diabetic foot ulcers (DFUs) are a major burden on the health-care system. The purpose of this study is to investigate factors affecting the healing rate of DFU in a university wound care center. Records of DFU patients treated between July 2013 and February 2015 were reviewed. Demographics, comorbidities, wound characteristics, and treatment modalities including offloading, hyperbaric oxygen treatment, total contact casting, and bioengineered skin were investigated. All patients underwent weekly debridement regardless of treatment modality. A total of 114 patients ages 18 to 98 comprised the study population. Total contact casting was the only treatment associated with increased healing ( P = 0.02). Smoking ( P = 0.004) and deep vein thrombosis history ( P = 0.001) significantly decreased the likelihood of wound healing. Patients with past vascular event trended toward longer healing times ( P = 0.07). Total contact casting in combination with weekly wound debridement showed benefit in DFU wound healing, whereas patients with a history of deep vein thrombosis and smoking were less likely to heal.

A Review of the Biomechanics of the Diabetic Foot

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

Effective and Economic Offloading of Diabetic Foot Ulcers in India with the Bohler Iron Plaster Cast

Economic constraints are a major obstacle to the implementation of offloading casts in India. The aim of this study is to monitor the healing and activity limitations related to Bohler iron plaster cast (BIPC) when used for offloading diabetic neuropathic plantar foot ulcers. Thirty patients were cast for 1 month and evaluated for healing using the Pressure Ulcer Scale for Healing (PUSH), and for activity limitation using the Lower Extremity Functional Scale (LEFS). The change in the scores after intervention was the outcome measure. There was good healing as evidenced by a statistical difference in mean PUSH scores. The baseline PUSH score of 9.76-0.41 (T1-SEM) was greater than follow-up PUSH score of 6.32 + 0.41 (T2 + SEM) and the p value <0.0001. Improvement was seen in ulcer area, exudate, and tissue type. There was no mobility effect as there was no significant difference in LEFS. Significant negative correlation was there between PUSH and LEFS. The r value was less than -0.7 both at baseline and after intervention. The combined benefits of good healing, lack of affect on lower extremity function, the ease of application and dressing, and relative affordability make BIPC a commendable offloading modality for the management of diabetic plantar ulcers.

Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot

Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.

Diabetic foot disease: From the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities

The burden of diabetic foot disease (DFD) is expected to increase in the future. The incidence of DFD is still rising due to the high prevalence of DFD predisposing factors. DFD is multifactorial in nature; however most of the diabetic foot amputations are preceded by foot ulceration. Diabetic peripheral neuropathy (DPN) is a major risk factor for foot ulceration. DPN leads to loss of protective sensation resulting in continuous unconscious traumas. Patient education and detection of high risk foot are essential for the prevention of foot ulceration and amputation. Proper assessment of the diabetic foot ulceration and appropriate management ensure better prognosis. Management is based on revascularization procedures, wound debridement, treatment of infection and ulcer offloading. Management and type of dressing applied are tailored according to the type of wound and the foot condition. The scope of this review paper is to describe the diabetic foot syndrome starting from the evaluation of the foot at risk for ulceration, up to the new treatment modalities.

[Surgical treatment of the Charcot foot : long-term results and systematic review]

BACKGROUND

Because of extensive bone loss and the associated complex instability and deformity of the feet, Charcot arthropathy or neuroosteoarthropathy is a challenge for the orthopedic surgeon. Ulcerations offer entry of various bacteria; thus, infections are a frequent serious issue and complication. The careful choice of treatment is not only very important for the correct alignment of the foot and the loading capacity, but also contributes significantly to the prevention of skin irritation or the healing of existing ulcers. Above all, chronic plantar ulcerations, caused by prominent exostoses or axial malalignments are almost untreatable without surgery. Because diagnosis requires an individual approach, no strict regimen of therapy has become established.

OBJECTIVES

The major objective was to reduce the number of ulcerations and infections, and to minimize the risk of amputation. In addition, complications and comorbidities were determined. Tibio-calcaneal arthrodesis is a very frequently used surgical treatment option. Therefore, a special focus in the following article is on this method.

MATERIALS AND METHODS

In a 12-year period (1999-2011), 43 patients (46 feet) suffering from Charcot foot were treated surgically. The following were used: triple, talo-navicular, subtalar, tibio-calcaneal arthrodesis and midfoot fusion bolts. The arthrodesis related to the hindfoot and tarsus and most commonly the tibio-calcaneal arthrodesis was applied. The reduction of load on the affected foot preoperatively and postoperatively by white-cast, Aircast walker shoe or other orthesis is essential in the treatment. For a long-term satisfactory outcome, an orthopedic custom-made shoe is indispensable after surgical treatment.

RESULTS

After surgical treatment of 16 feet with ulcerations, 14 could be healed and only 2 suffered from complications, such as infections, nonunions, talus necrosis, and wound healing disorder. Revision was frequently necessary, although the majority of complications could be treated. In this population, three amputations could not be prevented.

CONCLUSION

Even with strict aseptic techniques and years of experience in Charcot arthropathy, complications can occur, which can even lead to amputation. The early detection of the Charcot foot is the most important factor and helps to reduce morbidity and further complications. Co-morbid diseases (e.g., diabetes mellitus) need special care and optimal treatment, because they are often responsible for the poor surgical outcome. Finally, the ulceration rate and related complications, such as amputation, can be reduced by timely surgical treatment. Unfortunately, the progressive course of the disease often requires follow-up operations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Treatment of chronic plantar ulcer of the diabetic foot using an irremovable windowed fibreglass cast boot: prospective study of 177 patients

The objective of this study was to evaluate the level of healing of chronic neuropathic plantar ulcers, using an irremovable windowed fibreglass cast boot, which is only opened after healing. A single-centre prospective study of a cohort of 177 diabetic patients with chronic neuropathic plantar ulcers was carried out. The duration of neuropathic plantar ulcers was 604 ± 808 days, with a mean surface area of 4.6 ± 6.5 cm(2) , a mean depth of 1.04 ± 1.08 cm and a mean volume of 5.9 ± 17.7 cm(3) . After a mean of 96 days of wearing a windowed fibreglass cast boot (min 9 days, max 664 days and median 68 days), the level of healing reached 83.6%, although 29 patients did not heal (16.4%). The compliance was at 95%. NPUs with bigger volumes (p = 0.037) and those located at the heels ( p = 0.004) had significantly lower healing levels. Twenty-one patients had moderate peripheral arterial disease (12%), and 24 patients were ostectomized for underlying osteomyelitis (14%), before inclusion. Moderate peripheral arterial disease (p = 0.970) or operated osteomyelitis (p = 0.128) did not modify the level of healing significantly, which were of 81% and 70.8%, respectively. Complications include 12 ulcers due to the windowed fibreglass cast boot (i.e. 7%) and two other ulcers being moderately infected, resulting in 2% of toe amputation, but there was no major amputation or phlebitis. The treatment of old and deep NPUs of the diabetic foot by wearing a windowed fibreglass cast boot without opening the boot prior to healing offers very high ulcer recovery levels. Windowed fibreglass cast boots were changed in only 26 cases (14.6%). In addition, compliance was excellent and of the order of 95%. Furthermore, moderate peripheral arterial disease or a recent ostectomy did not affect the efficacy of windowed fibreglass cast boot.

Evaluation of lightweight fibreglass heel casts in the management of ulcers of the heel in diabetes: study protocol for a randomised controlled trial

Background

Ulcers of the heel in diabetes are the source of considerable suffering and cost. In the absence of specific treatments, it has been suggested that removable, lightweight fibreglass heel casts may both promote healing and reduce discomfort and pain. The aim of the study is to assess the effectiveness and cost-effectiveness of fibreglass heel casts in the management of heel ulcers.

Methods/Design

This is an observer-blind, randomised controlled trial in which participants with diabetes and heel ulcers (NPUAP/EPUAP grades 2, 3 or 4 and present for 2 or more weeks) are randomised to receive either usual care plus lightweight fibreglass heel casts or usual care alone. Randomisation is undertaken by random number sequence generation incorporated as part of the electronic case record form, and is stratified by both ulcer area (less than versus equal to or greater than 1 cm²) and NPUAP/EPUAP grade. Participants are followed every two weeks until healing or for 24 weeks. The primary outcome measure is healing at or before 24 weeks and maintained for 4 weeks. Secondary outcomes include (i) ulcer-related outcomes: time to healing, change in ulcer area, minor and major amputation, secondary infection and (ii) patient-related outcomes: local pain, mood and function (EQ-5D), impact of the ulcer (Cardiff Wound Impact Schedule) and survival. Cost-effectiveness will be assessed using a decision analytic model to estimate costs from the perspective of the UK NHS and personal social services and health outcomes, including percent healing and Quality Adjusted Life Years gained.

Safety will be documented as adverse and serious adverse device effects.

Discussion

If it is possible to confirm significant clinical benefit and/or cost-effectiveness, this would have direct implications for the management of this distressing and costly complication of diabetes

Trial registration number

ISRCTN62524796 Registered 29 March 2011

The management of diabetic foot ulcers through optimal off-loading: building consensus guidelines and practical recommendations to improve outcomes

BACKGROUND

We sought to develop a consensus statement for the use of off-loading in the management of diabetic foot ulcers (DFUs).

METHODS

A literature search of PubMed for evidence regarding off-loading of DFUs was initially conducted, followed by a meeting of authors on March 15, 2013, in Philadelphia, Pennsylvania, to draft consensus statements and recommendations using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to assess quality of evidence and develop strength of recommendations for each consensus statement.

RESULTS

Evidence is clear that adequate off-loading increases the likelihood of DFU healing and that increased clinician use of effective off-loading is necessary. Recommendations are included to guide clinicians on the optimal use of off-loading based on an initial comprehensive patient/wound assessment and the necessity to improve patient adherence with off-loading devices.

CONCLUSIONS

The likelihood of DFU healing is increased with off-loading adherence, and, current evidence favors the use of nonremovable casts or fixed ankle walking braces as optimum off-loading modalities. There currently exists a gap between what the evidence supports regarding the efficacy of DFU off-loading and what is performed in clinical practice despite expert consensus on the standard of care.

Contribution of infection and peripheral artery disease to severity of diabetic foot ulcers in Chinese patients

AIM

The objective of the current ongoing study was to evaluate the characteristics of diabetic patients with newly diagnosed foot ulcer in Burn & Plastic Hospital of PLA General Hospital.

METHODS

A total of 1002 consecutive patients presenting with a new foot ulcer between March 2007 and September 2013 were enrolled. All enrolled patients were classified based on presence or absence of collateral infection, disabling comorbidities and peripheral arterial disease (PAD).

RESULTS

Of patients, 70.05% had PAD, which occurred significantly more in elderly adults. Patients with PAD had higher incidence of infection (58.9% vs. 41.5% in non-PAD group) and disabling comorbidities (79% in PAD and 61% in non-PAD; p < 0.038). There was no significant difference observed in depth, size and duration of foot ulcers between the PAD and non-PAD group of enrolled diabetic patients.

CONCLUSIONS

Diabetic foot ulcer is more prominent in patients with PAD that is further reflected by significantly more underlying cases of infection and disabling comorbidity.

Is immobilization of the ankle and metatarsophalangeal joint effective in suppressing the spread of infection in diabetic foot ulcers?

Diabetics with foot-related problems might eventually need to undergo major or minor amputation because of infection or cellulites. It has been suggested that immobilization of the ankle and the metatarsophalangeal joint suppresses the spread of infection; however, there is no evidence to support this inference. Here, we demonstrate by histological analysis how the immobilization works. The tendon from the amputated toe is harvested, and a hematoxylin-eosin stained paraffin-embedded section is prepared and analyzed. Necrosis occurred in only a single fiber of the tendon, and intact and necrotic or infected tendon fibers were found intermingled. The reciprocal movements of the tendon and the joint (extension and flexion) may be the pathogenic cause of cellulites and infection, leading to the massage effect and the spread of bacteria along the tendon itself. We suggest that immobilizing the ankle and the metatarsophalangeal joint with a removable contacting cast would suppress the spread of infection in foot ulcers.

Ankle Injury Management (AIM): design of a pragmatic multi-centre equivalence randomised controlled trial comparing Close Contact Casting (CCC) to Open surgical Reduction and Internal Fixation (ORIF) in the treatment of unstable ankle fractures in patients over 60 years

BACKGROUND

Ankle fractures account for 9% of all fractures with a quarter of these occurring in adults over 60 years. The short term disability and long-term consequences of this injury can be considerable. Current opinion favours open reduction and internal fixation (ORIF) over non-operative treatment (fracture manipulation and the application of a standard moulded cast) for older people. Both techniques are associated with complications but the limited published research indicates higher complication rates of fracture malunion (poor position at healing) with casting. The aim of this study is to compare ORIF with a modification of existing casting techniques, Close Contact Casting (CCC). We propose that CCC may offer an equivalent functional outcome to ORIF and avoid the risks associated with surgery.

METHODS/DESIGN

This study is a pragmatic multi-centre equivalence randomised controlled trial. 620 participants will be randomised to receive ORIF or CCC after sustaining an isolated displaced unstable ankle fracture. Participants will be recruited from a minimum of 20 National Health Service (NHS) acute hospitals throughout England and Wales. Participants will be aged over 60 years and be ambulatory prior to injury. Follow-up will be at six weeks and six months after randomisation. The primary outcome is the Olerud & Molander Ankle Score, a functional patient reported outcome measure, at 6 months. Follow-up will also include assessments of mobility, ankle range of movement, health related quality of life and complications. The six-month follow-up will be conducted face-to-face by an assessor blinded to the allocated intervention. A parallel economic evaluation will consider both a health service and a broader societal perspective including the individual and their family. In order to explore patient experience of their treatment and recovery, a purposive sample of 40 patients will also be interviewed using a semi-structured interview schedule between 6-10 weeks post treatment.

DISCUSSION

This multicentre study was open to recruitment July 2010 and recruitment is due to be completed in December 2013.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN04180738.

Prognostic Improvement by Multidisciplinary Therapy in Patients With Critical Limb Ischemia

Although limb salvage rate has improved in critical limb ischemia (CLI), an improvement in CLI prognosis has been scarcely reported. Multidisciplinary therapy (MT) including revascularization, wound bed preparation, treatment of comorbidity, and education of patients with CLI may improve prognosis. The aim of this study was to investigate the effectiveness of MT in prognostic improvement. We retrospectively analyzed 72 patients with CLI and assessed whether MT improved prognosis. The incidence of amputation-free survival (freedom from major amputation [MA] and death) was significantly different between the MT and conventional groups at 2 years (0% vs 33%; P = .024). After multivariate analysis, transfusion (hazard ratio [HR] 5.778; 95% confidence interval [CI], 2.372-14.073; P < .001), multivessel coronary disease (HR 3.353; 95% CI, 1.309-8.590; P = .012), and C-reactive protein >5 mg/dL (HR 3.958; 95% CI, 1.359-11.531; P = .012) were independent predictors for MA or death. We concluded that MT was effective in improved mortality and limb salvage rate.

Randomised clinical trial to compare total contact casts, healing sandals and a shear-reducing removable boot to heal diabetic foot ulcers

The objective of this study was to evaluate the efficacy of three off-loading techniques to heal diabetic foot wounds: total contact casts (TCCs), healing sandals (HSs) and a removable boot with a shear-reducing foot bed (SRB). This was a 12-week, single-blinded randomised clinical trial with three parallel treatment groups of adults with diabetes and a foot ulcer (n = 73). Ulcer healing was defined as full reepithelialisation with no drainage. Diabetic patients with grade UT1A or UT2A forefoot ulcers on the sole of the foot were enrolled. Patients with malignancy, immune-compromising diseases, severe peripheral vascular disease (ankle-brachial index < 0·60 or transcutaneous oxygen < 25 mm/Hg), alcohol or substance abuse within 6 months, untreated osteomyelitis or Charcot arthropathy with residual deformity that would not fit the HS or boot were excluded. In the intent-to-treat analysis, significantly higher proportion of patients were healed in the TCC group (69·6%) compared to those treated with the SRB (22·2%, P < 0·05). There was no difference in the rate of healed ulcers in the HS (44·5%) and TCC groups. Ulcers in the TCC group healed faster than those in the HS group (5·4 ± 2·9 versus 8·9 ± 3·5 weeks, P < 0·02). However, there was no difference in the time to healing in the TCC and SRB groups (6·7 ± 4·3 weeks, P = 0·28). Patients who used HS were significantly more active (4022 ± 4652 steps per day, P < 0·05) than those treated with TCCs (1447 ± 1310) or SRB (1404 ± 1234). It is concluded that patients treated with TCCs had the highest proportion of healed wounds and fastest healing time. The novel shear-reducing walker had the lowest healing and highest rate of attrition during the study.

An integrated medical treatment for type-2 diabetes

This paper tries to emphasize two relevant concepts: the first is that type 2 diabetes is a chronic diseases characterized by both a dysmetabolism and a chronic oxidative stress. A variety of orthodox drugs are somewhat able to correct the metabolic alterations, but do not deal with the chronic inflammation. Consequently, as the validity of precisely treating blood with therapeutic ozone concentrations in restoring a redox homeostasis has been now demonstrated, the integration of ozone therapy appears essential for a rational treatment of type 2 diabetes. Such a combination may be able to reduce the diabetic epidemic.

Patient and professional delay in the referral trajectory of patients with diabetic foot ulcers

AIMS

A cohort study investigated referral and treatment trajectories of patients with diabetic foot ulceration consulting podiatrists. The study aims were to quantify patient, professional and treatment (=total) delay and to identify relationships between patient- or professional-related characteristics, delays or ulcer healing time.

METHODS

Ten podiatrists specialising in diabetes care included 54 consecutive adults with diabetic foot ulceration. Assessments were performed retrospectively (e.g. delays) and prospectively (12 weeks).

RESULTS

Median (SD; range) patient delay was 3.0 days (50.6; 0-243), professional delay 7.0 days (63.4; 0-279) and treatment delay 20.5 days (97.3; 0-522). 57% of patients took >2 weeks before visiting a podiatrist. Ulcers healed in 67% of patients in 49.0 days (90.2; 4-408). The number of health care professionals in the referral trajectory was positively related to treatment delay (p<0.01) and to ulcer healing time (p<0.01). Professional delay and treatment delay was positively correlated with the duration of the podiatric treatment (p<0.05). Patient awareness of ulceration risk tended to decrease the healing time.

CONCLUSIONS

Patients with diabetic foot ulcers presented small median delays in the referral trajectory to podiatrists specialising in diabetes. The study results suggest that reducing the number of health care professionals in the referral trajectory might decrease treatment delay and ulcer healing time. Also improving patient awareness of ulceration risk might be beneficial for the healing time.