Search Results
Nerve Decompression After Diabetic Foot Ulceration May Protect Against Recurrence
A 3-Year Controlled, Prospective Analysis
Background
Nerve entrapment, common in diabetes, is considered an associated phenomenon without large consequence in the development of diabetes complications such as ulceration, infection, amputation, and early mortality. This prospective analysis, with controls, of the ulcer recurrence rate after operative nerve decompression (ND) offers an objective perspective on the possibility of frequent occult nerve entrapment in the diabetic foot complication cascade.
Methods
A multicenter cohort of 42 patients with diabetic sensorimotor polyneuropathy, failed pharmacologic pain control, palpable pulses, and at least one positive Tinel's nerve percussion sign was treated with unilateral multiple lower-leg external neurolyses for the indication of pain. All of the patients had healed at least one previous ipsilateral plantar diabetic foot ulceration (DFU). This group was retrospectively evaluated a minimum of 12 months after operative ND and again 3 years later. The recurrence risk of ipsilateral DFU in that period was prospectively analyzed and compared with new ulcer occurrence in the contralateral intact, nonoperated control legs.
Results
Operated legs developed two ulcer recurrences (4.8%), and nine contralateral control legs developed ulcers (21.4%), requiring three amputations. Ulcer risk is 1.6% per patient per year in ND legs and 7% in nonoperated control legs (P = .048).
Conclusions
Adding operative ND at lower-leg fibro-osseous tunnels to standard postulcer treatment resulted in a significantly diminished rate of subsequent DFU in neuropathic high-risk feet. This is prospective, objective evidence that ND can provide valuable ongoing protection from DFU recurrence, even years after primary ulcer healing.
Objective
Porcine-derived xenograft biological dressings (PXBDs) are occasionally used to prepare chronic wound beds for definitive closure before split-thickness skin grafts (STSGs). We sought to determine whether PXBD influences rate of STSG take in lower-extremity wounds.
Methods
Lower-extremity wounds treated with STSGs were retrospectively reviewed. Patients were included in one of two groups: wound bed preparation with PXBD before STSG or no preparation. Patients were excluded if they received wound bed preparation via another method. Patient demographics, comorbidities, wound history, wound bed preparation, and 30- and 60-day outcomes were collected.
Results
There was no difference in healing outcomes between the PXBD (n = 27) and no preparation (n = 39) groups. At 30- and 60-day follow-up, percentage of STSG take was not significantly different between groups (77.9% versus 79.0%, P30 = .818; 82.2% versus 80.9%, P60 = .422). Mean wound sizes at these follow-up periods were not different (4.4 cm2 versus 5.1 cm2, P30 = .902; 1.2 cm2 versus 1.1 cm2, P60 = .689). The PXBD group had a higher mean ± SD hemoglobin A1c level (8.3 ± 3.5 versus 6.9 ± 1.6; P = .074) and age (64.9 ± 12.8 years versus 56.3 ± 11.9 years; P = .007) versus the no preparation group.
Conclusions
Application of PXBDs for wound bed preparation had no effect on wound healing compared with no wound bed preparation. The two groups varied only by mean age and hemoglobin A1c level. The PXBD may be beneficial, but these results call for randomized controlled trials to determine the true impact of PXBDs on wound healing. In addition, PXBDs may have utility outside of clinically oriented outcomes, and future work should address patient-reported outcomes and pain scores with this adjunct.
Background:
Elevated dynamic plantar pressures are a consistent finding in diabetic patients with peripheral neuropathy, with implications for plantar foot ulceration. This study aimed to investigate whether a first-ray amputation affects plantar pressures and plantar pressure distribution patterns in individuals living with diabetes and peripheral neuropathy.
Methods:
A nonexperimental matched-subject design was conducted. Twenty patients living with diabetes and peripheral neuropathy were recruited. Group 1 (n = 10) had a first-ray amputation and group 2 (n = 10) had an intact foot with no history of ulceration. Plantar foot pressures and pressure-time integrals were measured under the second to fourth metatarsophalangeal joints, fifth metatarsophalangeal joint, and heel using a pressure platform.
Results:
Peak plantar pressures under the second to fourth metatarsophalangeal joints were significantly higher in participants with a first-ray amputation (P = .008). However, differences under the fifth metatarsophalangeal joint (P = .734) and heel (P = .273) were nonsignificant. Pressure-time integrals were significantly higher under the second to fourth metatarsophalangeal joints in participants with a first-ray amputation (P = .016) and in the heel in the control group (P = .046).
Conclusions:
Plantar pressures and pressure-time integrals seem to be significantly higher in patients with diabetic peripheral neuropathy and a first-ray amputation compared with those with diabetic neuropathy and an intact foot. Routine plantar pressure screening, orthotic prescription, and education should be recommended in patients with a first-ray amputation.
Contralateral Peak Plantar Pressures with a Postoperative Boot
A Preliminary Study
Background: Frequent use of walking boots in podiatric medicine often elicits patient complaints and sequelae from the imposed limb-length discrepancy. This study was designed primarily to determine whether peak plantar pressures are decreased in the contralateral foot when a moderately worn athletic shoe is worn opposite a high-calf walking boot and, if so, secondarily to determine whether a specialized surgical shoe worn on the contralateral foot can also effectively reduce this pressure. The pressure reductions were then compared to determine whether significantly greater plantar pressure reduction was provided by either the athletic shoe or the surgical shoe.
Methods: Participants without a foot abnormality walked on a treadmill in four footwear combinations: barefoot bilaterally, high-calf rocker-bottom sole (HCRB) walking boot/ barefoot, HCRB walking boot/athletic shoe, and HCRB walking boot/modified walking boot shoe. Measurements were taken with the participants wearing socks. Peak plantar calcaneal pressures were collected.
Results: Peak plantar pressures under the calcaneus opposite the HCRB walking boot were significantly reduced from barefoot pressures when either an athletic shoe or the modified walking boot shoe was worn. However, no significant difference was seen when comparing the reduction by the athletic shoe with that by the modified walking boot.
Conclusions: Wearing an athletic shoe on the foot opposite an HCRB walking boot reduces calcaneal pressures; however, wearing a modified device with structural properties of an HCRB walking boot sole is no better than an athletic shoe at reducing peak calcaneal pressures. (J Am Podiatr Med Assoc 101(2): 127–132, 2011)
Several nonbiodegradable and biodegradable antibiotic cement delivery systems are available for the delivery of antibiotics for adjunctive therapy in the management of osteomyelitis. A major nonbiodegradable delivery system is polymethylmethacrylate beads. Antibiotics that can be incorporated into this delivery system are limited to the heat-stable antibiotics vancomycin and aminoglycosides, tobramycin being the most popular. Calcium sulfate and hydroxyapatite (Cerament Bone Void Filler) is a unique biocompatible and biodegradable ceramic bone void filler that can successfully deliver heat-stable and heat-unstable antibiotics in musculoskeletal infections. The use of Cerament as antibiotic beads has not been previously reported. An off-label case of diabetic foot osteomyelitis successfully managed with surgical bone resection and vancomycin Cerament antibiotic beads is presented. Subsequent surgery for the bone infection and staged removal of the antibiotic beads was not necessary. (J Am Podiatr Med Assoc 101(3): 259–264, 2011)
The timely and accurate noninvasive assessment of peripheral arterial disease is a critical component of a limb preservation initiative in patients with diabetes mellitus. Noninvasive vascular studies can be useful in screening patients with diabetes for peripheral arterial disease. In patients with clinical signs or symptoms, noninvasive vascular studies provide crucial information on the presence, location, and severity of peripheral arterial disease and an objective assessment of the potential for primary healing of an index wound or a surgical incision. Appropriately selected noninvasive vascular studies are important in the decision-making process to determine whether and what type of intervention might be most appropriate given the clinical circumstances. Hemodynamic monitoring is likewise important after either an endovascular procedure or a surgical bypass. Surveillance studies, usually with a combination of physiologic testing and imaging with duplex ultrasound, accurately identify recurrent disease before the occurrence of thrombosis, allowing targeted reintervention. Noninvasive vascular studies can be broadly grouped into three general categories: physiologic or hemodynamic measurements, anatomical imaging, and measurements of tissue perfusion. These types of tests and suggestions for their appropriate application in patients with diabetes are reviewed. (J Am Podiatr Med Assoc 100(5): 406–411, 2010)
Background: Several studies have established an association between diabetic neuropathy and depressive symptoms. There is a link between depression and peripheral neuropathy in diabetic patients, suggesting an increased likelihood that diabetic patients will experience depressive symptoms related to lower-extremity peripheral neuropathy and arthritis during middle age and later life. The goal of this investigation was to determine whether there are age differences between insulin-dependent and non-insulin-dependent diabetic patients regarding their feelings of hopelessness and toe pain.
Methods: A large population-based sample of 32,006 adults from the 1998 National Health Interview Survey was analyzed with multivariate statistical procedures. We performed χ2 and correlation procedures to test the null hypothesis that there are no age or sex differences between insulin-dependent and non-insulin-dependent diabetic patients in their reporting of feelings of hopelessness and toe pain symptoms in the previous 12 months.
Results: There were significant differences between age and sex groups of insulin-dependent and non-insulin-dependent diabetic patients in reporting feelings of hopelessness and toe pain symptoms, rejecting the null hypothesis. Correlational analysis conducted between the variables of hopelessness and toe pain yielded significant correlations in insulin-dependent (r = .28; P = .0009; α = .05), and non-insulin-dependent (r = 0.19; P = .001; α = .05) women older than 61 years, concluding that diabetic women are more likely to experience hopelessness and toe pain in that age group regardless of insulin status.
Conclusions: Clinicians should incorporate depression and toe pain symptoms into their assessment and treatment, especially in diabetic women older than 61 years. (J Am Podiatr Med Assoc 100(6): 445–451, 2010)
Background:
We sought to determine the prevalence of lower-extremity arterial calcification in a cohort of patients with diabetes and associated foot pathology receiving inpatient treatment at an urban US tertiary health-care system.
Methods:
The primary outcome measure was defined as either radiographic evidence of vessel calcification or noninvasive vascular testing that resulted in any reporting of vessel noncompressibility or an ankle-brachial index greater than 1.1. Radiographic evidence of vessel calcification was defined as radiodense calcification in the proximal first intermetatarsal space (deep plantar perforating artery), anterior ankle (anterior tibial artery), or posterior ankle (posterior tibial artery) on dorsoplantar and lateral foot projections.
Results:
Of the 367 individuals included in the study, 359 underwent radiography, with radiographic evidence of calcification in 192 (53.5%). Noninvasive vascular testing was performed on 265 participants, with any reporting of noncompressibility or an ankle-brachial index greater than 1.1 observed in 153 (57.7%). Ninety-four participants (25.6%) demonstrated evidence of arterial calcification on the radiographs and noninvasive testing, meaning that 251 participants (68.4%) demonstrated evidence of arterial calcification on at least one test, including 63.6% of participants classified as black/African American race, 65.4% as white race, and 78.3% as Hispanic/Latino ethnicity.
Conclusions:
The results of this investigation increase the body of knowledge with respect to the evaluation and treatment of diabetic foot disease and may lead to future investigations on the topic of lower-extremity arterial calcification.
Background:
The aim of this study was to observe the pressure changes in the felt padding used to off-load pressure from the first metatarsal head, the effects obtained by different designs, and the loss of effectiveness over time.
Method:
With a study population of 17 persons, two types of 5-mm semicompressed felt padding were tested: one was C-shaped, with an aperture cutout at the first metatarsophalangeal joint, and the other was U-shaped. Pressures on the sole of the foot were evaluated with a platform pressure measurement system at three time points: before fitting the felt padding, immediately afterward, and 3 days later.
Results:
In terms of decreased mean pressure on the first metatarsal, significant differences were obtained in all of the participants (P < .001). For plantar pressures on the central metatarsals, the differences between all states and time points were significant for the C-shaped padding in both feet (P < .001), but with the U-shaped padding the only significant differences were between no padding and padding and at day 3 (P = .01 and P = .02).
Conclusions:
In healthy individuals, the U-shaped design, with a padding thickness of 5 mm, achieved a more effective and longer-lasting reduction in plantar pressure than the C-shaped design.
Background
Homeless people live in poverty, with limited access to public health services. They are likely to experience chronic medical conditions, such as diabetes mellitus; however, they do not always receive the necessary services to prevent complications. This study was designed to determine the effectiveness of a volunteer health service outreach to reduce disparity in diabetic foot care for homeless people.
Methods
The research was conducted on 21 patients with diabetic ulcers of 930 homeless people visited between 2008 and 2013. Each ulcer was treated with regular medication every week for a mean ± SD of 17.6 ± 12 months. The inclusion criteria were 1) homeless with a previous diagnosis of diabetes or a blood glucose level greater than 126 mg/dL at first check and 2) foot ulcer caused by diabetic vasculopathy or neuropathy. The efficacy of the interventions was assessed against the number of successfully cured diabetic feet based on a reduced initial Wagner classification score for each ulcer.
Results
Clinical improvement was observed in 18 patients (86%), whose pathologic condition was completely resolved after 3 years and, therefore, no longer needed medication. One patient died of septic shock and kidney failure, and two patients needed amputation owing to clinical worsening of ulcers (Wagner class 4 at the last visit).
Conclusions
Most homeless people who have diabetes and diabetic foot encounter many difficulties managing their disease, and a volunteer health-care unit could be a suitable option to bridge these gaps.
