Although effective, oral antifungal therapy is still not completely successful. Recent studies have shown that combination therapy with oral and topical agents offers an increased cure rate for patients. We review the main drug combinations that have been tested. Additional measures, such as mechanical intervention, may help improve response rates further. (J Am Podiatr Med Assoc 96(2): 116–119, 2006)
We sought to determine patient and ulcer characteristics that predict wound healing in patients living with diabetes.
A prospective observational study was conducted on 99 patients presenting with diabetic foot ulceration. Patient and ulcer characteristics were recorded. Patients were followed up for a maximum of 1 year.
After 1 year of follow-up, ulcer characteristics were more predictive of ulcer healing than were patient characteristics. Seventy-seven percent of ulcers had healed and 23% had not healed. Independent predictors of nonhealing were ulcer stage (P = .003), presence of biofilm (P = .020), and ulcer depth (P = .028). Although this study demonstrated that the baseline hemoglobin A1c reading at the start of the study was not a significant predictor of foot ulcer outcome (P = .603, resolved versus amputated), on further statistical analyses, when hemoglobin A1c was compared with the time taken for complete ulcer healing (n = 77), it proved to be significant (P = .009).
The factors influencing healing are ulcer stage, presence of biofilm, and ulcer depth. These findings have important implications for clinical practice, especially in an outpatient setting. Prediction of outcome may be helpful for health-care professionals in individualizing and optimizing clinical assessment and management of patients. Identification of determinants of outcome could result in improved health outcomes, improved quality of life, and fewer diabetes-related foot complications.
Diabetes-related lower limb amputations (LLAs) are a major complication that can be reduced by employing multidisciplinary center frameworks such as the Toe and Flow model (TFM). In this study, we investigate the LLAs reduction efficacy of the TFM compared to the standard of care (SOC) in the Canadian health-care system.
We retrospectively reviewed the anonymized diabetes-related LLA reports (2007-2017) in Calgary and Edmonton metropolitan health zones in Alberta, Canada. Both zones have the same provincial health-care coverage and similar demographics; however, Calgary operates based on the TFM while Edmonton with the provincial SOC. LLAs were divided into minor and major amputation cohorts and evaluated using the chi-square test, linear regression. A lower major LLAs rate was denoted as a sign for higher efficacy of the system.
Although LLAs numbers remained relatively comparable (Calgary: 2238 and Edmonton: 2410), the Calgary zone had both significantly lower major (45%) and higher minor (42%) amputation incidence rates compared to the Edmonton zone. The increasing trend in minor LLAs and decreasing major LLAs in the Calgary zone were negatively and significantly correlated (r = -0.730, p = 0.011), with no significant correlation in the Edmonton zone.
Calgary's decreasing diabetes-related major LLAs and negative correlation in the minor-major LLAs rates compared to its sister zone Edmonton, provides support for the positive impact of the TFM. This investigation includes support for a modernization of the diabetes-related limb preservation practice in Canada by implementing TFMs across the country to combat major LLAs.
Health and Safety in Podiatric Medicine
Findings from a National Survey of Irish Podiatric Physicians
Much of the research into health and safety in podiatric medicine to date has focused on measuring particular hazards. This study examines legislative awareness and compliance in Irish podiatric medical practices and aspects of health and safety practice.
Podiatric physicians practicing in Ireland completed a cross-sectional questionnaire survey that included measures of health and safety knowledge and awareness, compliance with legislative requirements, perceived risks, and health status.
Of 250 podiatric physicians who were contacted, 101 completed the survey (response rate, 40%). Legislative knowledge and compliance were low among respondents. A Student t test revealed that the use of safety control measures was more frequent among podiatric physicians in practice for less than 20 years (P < .05). Musculoskeletal disorders and back injuries were the most frequently reported health concerns.
This study demonstrates the need for interventions to increase awareness of legislative requirements among podiatric physicians as a first step to increase levels of regulatory compliance.
Diabetic Foot Ulcers Treated with Becaplermin and TheraGauze, a Moisture-Controlling Smart Dressing
A Randomized, Multicenter, Prospective Analysis
Background: It is hypothesized that moisture regulation specific to the area of contact results in local wound conditions more amenable to healing, which would result in faster and more frequent wound closure. TheraGauze is a new polymer-impregnated dressing designed to regulate moisture to a varying degree over the entire surface of a wound.
Methods: This prospective, randomized, multicenter study examined outcomes from treatment of diabetic foot ulcers with TheraGauze and TheraGauze in conjunction with becaplermin. We also compared these outcomes with historical data from the literature that used saline-moistened gauze and becaplermin.
Results: The rates of wound closure with TheraGauze and TheraGauze + becaplermin were 0.37 and 0.41 cm2/week, respectively (P = .34). The difference between these values was not statistically significant. We also observed high closure rates at 12 weeks (46.2% in both groups) and 20 weeks (61.5% with TheraGauze alone and 69.2% with TheraGauze + becaplermin). These data were also compared with historical data for closure rates (0.18 cm2/week) and percentage of wounds closed using saline-moistened gauze alone and becaplermin with saline-moistened gauze (0.24 cm2/week) from a variety of studies.
Conclusions: Wounds in which moisture content was regulated with TheraGauze showed more rapid change in wound area and a higher percentage of wounds achieving closure at 12 and 20 weeks regardless of whether becaplermin was used. (J Am Podiatr Med Assoc 100(3): 155–160, 2010)
Combined Popliteal and Saphenous Nerve Blocks at the Knee
An Underused Alternative to General or Spinal Anesthesia for Foot and Ankle Surgery
Peripheral nerve blocks at the ankle have long been used for foot surgery. However, when local foot and ankle blocks are inappropriate or contraindicated, general and spinal anesthesia are the common alternatives. Both have disadvantages and require added equipment and monitors. Combined popliteal and saphenous nerve blocks at the knee can offer a desirable alternative to general and spinal anesthesia for foot and ankle surgery. In addition, popliteal and saphenous nerve blocks provide anesthesia of the entire lower leg, thus permitting a greater variety of procedures to be performed. This article reviews the anatomical considerations, various block techniques, and surgical applications of this useful approach to lower-leg anesthesia. (J Am Podiatr Med Assoc 94(4): 368–374, 2004)
Onychogryphosis is a nail disorder that can damage nail plates, usually caused by repeated minor trauma to the foot. Onychogryphosis of the toe is commonly seen in clinical practice; however, optimal treatment of the condition is still the subject of debate. The purpose of this study was to evaluate clinical outcomes of patients with toe onychogryphosis treated by subcutaneous flap coverage after total matricectomy.
In this article, we describe 12 patients who had onychogryphosis on the great toe treated by subcutaneous flap coverage after total matricectomy. There were eight men and four women, with a mean age of 63.8 years (range, 56–74 years).
The follow-up period ranged from 4 to 108 months, with an average of 25.2 months. All of the flap reconstructions ultimately survived.
The advantage of the described technique is the avoidance of tight closure of the skin and preservation of toe length. The possible limitation of the technique is poor blood circulation to the feet.
Previous study indicates that pharmacologic antithrombotic therapy may be an inhibitory factor for wound healing and should merit consideration among the other core factors in wound healing optimization.
This study provides a retrospective analysis of the effect of antithrombotic therapy on wound healing rates of uncomplicated diabetic foot ulcerations. Wounds treated with standard of care in the presence of clinical anticoagulation were compared to control wounds.
The results indicate a statistically significant negative correlation between antithrombotic therapy and diabetic foot wound healing rate. This represents the first study focusing on this correlation in the uncomplicated diabetic foot wound.
This retrospective study demonstrates that antithrombotic therapy has a statistically significant negative effect on healing rates of uncomplicated diabetic foot ulcerations. Both wound area and depth improvement over 4 weeks was significantly better in treated patients who were not on antithrombotic therapy for comorbidity not associated with peripheral arterial disease.
We sought to demonstrate the healing efficacy of an antimicrobial hydrogel containing Oakin, an oak extract, to heal postoperative partial and total chemical matrixectomies.
Sixty participants were eligible for this open-label prospective study by having an ingrown toenail and a willingness to have the ingrown portion of the nail or the entire toenail permanently removed. All of the participants underwent a similar nail surgery, were provided a postoperative kit that included the study hydrogel, and received the same sheet of instructions for aftercare.
Fifty-four participants could be contacted for follow-up and final evaluation; 54% (n = 29) were men and 46% (n = 25) were women. Eighty-nine partial hallux nail avulsions with phenol matrixectomy were performed. The median ± SD time to healing was 7.00 ± 0.00 days for 80% of participants (n = 43) and 8.85 ± 4.15 days for 98% (n = 53). An analysis of variance showed that the proportion healed time trend is significant (F 1,53 = 79.265; P < .001).
The study hydrogel's ability to stop phenol's caustic activity is clinically beneficial in phenol matrixectomy aftercare. Providing each participant with a kit that included the same dressing supplies yielded consistent aftercare outcomes and 98% patient satisfaction (n = 53). The findings show that the Oakin-containing hydrogel was efficacious in healing phenol matrixectomies without the need for soaking. Furthermore, we suggest that the study hydrogel could also reduce healing times.
In this retrospective review, 19 diabetic patients with significant lower-extremity pathology were assessed to determine the success of limb salvage in cases of varying complexity. The patients were either scheduled or at risk for below-the-knee amputation before intervention. After the limb-salvage procedure, patients were followed for 4 months to 9 years. Eighteen patients went on to have successful procedures, avoiding below-the-knee amputation; one patient had an above-the-knee amputation. The results demonstrate the benefits of an aggressive team approach with limb salvage as a goal. (J Am Podiatr Med Assoc 92(8): 457-462, 2002)