Patients with chronic diabetes have a broad spectrum of associated peripheral neurologic deficits that culminate in an increased susceptibility to ulcer formation. The authors focus on the use of the ankle-foot orthosis as both a treatment and a definitive solution for achieving ulcer closure and for minimizing the chance of ulcer recurrence in the ambulatory patient. An analysis of the pathologic forces encountered, and the solution achieved with the ankle-foot orthosis is presented. In addition, the results from a clinical pilot study in subjects with recalcitrant ulcers secondary to Charcot's neuroarthropathy are presented.
Does Footwear Affect Balance?
The Views and Experiences of People with Diabetes and Neuropathy Who Have Fallen
Despite falls being a major concern for people living with somatosensory deficit, little is known about the perceived impact of footwear and footwear features on balance. Clinical relevance is increased given that therapeutic footwear is often provided to people with diabetes to reduce foot ulcer risk. This qualitative study aims to explore the experiences and views of people with diabetes and neuropathy who have recently fallen to understand whether footwear type is perceived to affect balance or contribute to falling.
Sixteen individuals (13 men and three women aged 44–83 years) were purposively sampled from a larger population of potential participants. Audio-recorded, in-depth, semistructured interviews were conducted in participant homes or at a place preferable to them. Once transcribed verbatim, the data were themed, charted, and interpreted using a framework approach.
Although most participants did not believe that the footwear in which they fell contributed to their fall, most revealed how footwear choice influenced their balance confidence to undertake daily tasks. Most found their therapeutic footwear “difficult” to walk in, “heavy, or “slippery bottomed.” Design recommendations for enhanced balance included a close fit with tight fastening, lightweight, substantial tread, and a firm, molded sole/insole. Complying with these recommendations, the hiking sandal was believed to be the most stable and safe shoe and was frequently worn as a walking aid to reduce fear of falling and boost confidence.
People with diabetic neuropathy have disease-specific needs and concerns relating to how footwear affects balance. Engaging with patients to address those needs and concerns is likely to improve the feasibility and acceptability of therapeutic footwear to reduce foot ulcer risk and boost balance confidence. (J Am Podiatr Med Assoc 103(6): 508–515, 2013)
Background: Off-loading excessive pressure is essential to healing diabetic foot ulcers. However, many patients are not compliant in using prescribed footwear or off-loading devices. We sought to validate a method of objectively measuring off-loading compliance via activity monitors.
Methods: For 4 days, a single subject maintained a written compliance diary concerning use of a removable cast walker. He also wore a hip-mounted activity monitor during all waking hours. An additional activity monitor remained mounted on the cast walker at all times. At the conclusion of the 4 days, the time-stamped hip activity data were independently coded for walker compliance by the compliance diary and by using the time-stamped walker activity data.
Results: An intraclass reliability of 0.93 was found between diary-coded and walker monitor–coded activity.
Conclusions: These results support the use of this dual activity monitor approach for assessing off-loading compliance. An advantage of this approach versus a patient-maintained diary is that the monitors are not susceptible to incorrect patient recall or a patient’s desire to please a caregiver by reporting inflated compliance. Furthermore, these results seem to lend support to existing reports in the literature using similar methods. (J Am Podiatr Med Assoc 99(2): 100–103, 2009)
Digestion of collagen with clostridial collagenase (CC) produces peptides that can induce cellular responses consistent with wound healing in vivo. However, nonhealing human wounds are typically in a state of chronic inflammation. We evaluated the effects of CC on markers of inflammation in cell culture and wound fluid from diabetic patients.
Lipopolysaccharide-induced release of tumor necrosis factor-α and interleukin-6 from interferon-γ–activated THP-1 monocytes was measured in the presence or absence of CC or CC collagen digests. In the clinical study, 17 individuals with mildly inflamed diabetic foot ulcers were randomized to receive CC ointment (CCO) or hydrogel. Weekly assessments included wound appearance and measurements. Wound exudate was collected at baseline and at 2 and 4 weeks of treatment. A multiplex assay was used to measure levels of analytes, including those associated with inflammation and with inflammation resolution.
Lower levels of tumor necrosis factor-α and interleukin-6 were found in media of cells cultured with CC or CC digests of collagen type I or III than for untreated lipopolysaccharide controls (P < .05). Clinically, CCO and hydrogel resulted in improvement in wound appearance and a decrease in mean wound area. The CCO, but not the hydrogel, was found to increase the level of analytes associated with resolution of inflammation while decreasing those associated with inflammation. There was a general correlation between resolution of inflammation and healing.
These results support a hypothesis that debridement with CCO is associated with decreased inflammation and greater progress toward healing.
This article reports on a case of malignant degeneration of a hallux nail bed ulcer of 30 years' duration. Histologically, this lesion was determined to be a squamous cell carcinoma, a type of lesion that is also known as Marjolin's ulcer. The diagnosis, histologic findings, and treatment of patients with cutaneous squamous cell carcinoma are discussed.
We evaluated whether direct or indirect endovascular revascularization based on the angiosome model affects outcomes in type 2 diabetes and critical limb ischemia.
From 2010 to 2015, 603 patients with type 2 diabetes were admitted for critical limb ischemia and submitted to endovascular revascularization. Among these patients, 314 (52%) underwent direct and 123 (20%) indirect revascularization, depending on whether the flow to the artery directly feeding the site of ulceration, according to the angiosome model, was successfully acquired; 166 patients (28%) were judged unable to be revascularized. Outcomes were healing, major amputation, and mortality rates.
An overall healing rate of 62.5% was observed: patients who did not receive percutaneous transluminal angioplasty presented a healing rate of 58.4% (P < .02 versus revascularized patients). A higher healing rate was observed in the direct versus the indirect group (82.4% versus 50.4%; P < .001). The major amputation rate was significantly higher in the indirect versus the direct group (9.2% versus 3.2%; P < .05). The overall mortality rate was 21.6%, and it was higher in the indirect versus the direct group (24% versus 14%; P < .05).
These data show that direct revascularization of arteries supplying the diabetic foot ulcer site by means of the angiosome model is associated with a higher healing rate and lower risk of amputation and death compared with the indirect procedure. These results support use of the angiosome model in type 2 diabetes with critical limb ischemia.
Acral lentiginous melanoma is commonly misdiagnosed, and when detected late it portends a poor prognosis. Acral lentiginous melanoma can be mistaken for verruca, pyogenic granuloma, poroma, an ulcer, or other benign skin conditions. Patients with acral skin growths often present initially to a podiatric physician or their primary care physician. It is at this point when the growth is triaged as benign or potentially malignant. Dermoscopy aids in this decision making. Historically, dermoscopy training has been geared toward dermatologists, but there is increasing recognition of the need for dermoscopy training in primary care and podiatric medicine. Dermoscopy is particularly helpful in pink (amelanotic) growths, which can lack the traditional clinical findings of melanoma. A literature review of acral melanoma and dermoscopy was performed in PubMed. We also describe a case of amelanotic acral melanoma in a 58-year-old with a rapidly enlarging painful mass on her heel. The lesion was initially thought to be a pyogenic granuloma and was treated with debridement (curettage). She was ultimately seen in the dermatology clinic, and the findings under dermoscopy were worrisome for amelanotic melanoma. Biopsy confirmed the diagnosis. The cancer metastasized, and the patient died less than 2 years later.
For several years, confectioned or customized interdigital silicone orthoses have been used to treat toe malformations; however, long-term clinical and biomechanical studies are missing. The aim of this study was to evaluate the biomechanical effects of these orthoses and their clinical acceptance.
In 2008, 46 patients (30 women and 16 men; average age, 56.8 years) received interdigital silicone orthoses. All of the patients were included in the biomechanical and clinical study. Compliance and acceptance were measured by the Muenster shoe and foot questionnaire, which includes 13 items on pain, activities of daily living, satisfaction, and activity. Mean follow-up was 18 months. Ten feet (eight patients) were chosen by random and underwent pedobarography. One forefoot sensor and two single sensors were attached between the skin and the orthosis. Measurements were performed in-shoe three times with and without the orthosis without removal of the sensors.
Forty-four of the 46 patients (95.7%) were included. At the 18-month investigation, 19 patients no longer used their orthoses, most commonly because of pain and failure of the material. Twenty-two patients regularly used their orthoses (8 h/d on average). In-shoe peak pressure lowered significantly with orthosis use (P < .04). Patients who used the orthoses were mostly satisfied.
Interdigital silicone orthoses reduce in-shoe peak pressure. Patient satisfaction was good. The durability of the material has to be optimized, and manufacturing remains difficult. The effect on ulcer reduction must be evaluated in a large prospective study.
Background: A feasibility study was conducted to characterize the effects of noncontact low-frequency ultrasound therapy for chronic, recalcitrant lower-leg and foot ulcerations.
Methods: The study was an open-label, nonrandomized, baseline-controlled clinical case series. Patients were initially treated with the Mayo Clinic standard of care before the addition of or the switch to noncontact low-frequency ultrasound therapy. We analyzed the medical records of 51 patients (median ± SD age, 72 ± 15 years) with one or more of the following conditions: diabetes mellitus, neuropathy, limb ischemia, chronic renal insufficiency, venous disease, and inflammatory connective tissue disease. All of the patients had lower-extremity ulcers, 20% had a history of amputation, and 65% had diabetes. Of all the wounds, 63% had a multifactorial etiology, and 65% had associated transcutaneous oximetry levels below 30 mm Hg.
Results: The mean ± SD treatment time of wounds during the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 9.8 ± 5.5 weeks versus 5.5 ± 2.8 weeks (P < .0001). Initial and end measurements were recorded, and percent volume reduction of the wound was calculated. The mean ± SD percent volume reduction in the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 37.3% ± 18.6% versus 94.9% ± 9.8% (P < .0001).
Conclusions: Using noncontact low-frequency ultrasound improved the rate of healing and closure in recalcitrant lower-extremity ulcerations. (J Am Podiatr Med Assoc 97(2): 95–101, 2007)
Is TCC-EZ a Suitable Alternative to Gold Standard Total-Contact Casting?
A Plantar Pressure Analysis
The total-contact cast (TCC) is the gold standard for off-loading diabetic foot ulcers (DFUs) given its nonremovable nature. However, this modality remains underused in clinical settings due to the time and experience required for appropriate application. The TCC-EZ is an alternative off-loading modality marketed as being nonremovable and having faster and easier application. This study aims to investigate the potential of the TCC-EZ to reduce foot plantar pressures.
Twelve healthy participants (six males, six females) were fitted with a removable cast walker, TCC, TCC-EZ, and TCC-EZ with accompanying brace removed. These off-loading modalities were tested against a control. Pedar-X technology measured peak plantar pressures in each condition. Statistical analysis of four regions of the foot (rearfoot, midfoot, forefoot, and hallux) was conducted with Friedman and Wilcoxon signed rank tests. Significance was set at P < .05.
All of the off-loading conditions significantly reduced pressure compared with the control, except the TCC-EZ without the brace in the hallux region. There was no statistically significant difference between TCC-EZ and TCC peak pressure in any foot region. The TCC-EZ without the brace obtained significantly higher peak pressures than with the brace. The removable cast walker produced similar peak pressure reduction in the midfoot and forefoot but significantly higher peak pressures in the rearfoot and hallux.
The TCC-EZ is a viable alternative to the TCC. However, removal of the TCC-EZ brace results in minimal plantar pressure reduction, which might limit clinical applications of the TCC-EZ.