Wound repair and regeneration is a highly complex combination of matrix destruction and reorganization. Although major hurdles remain, advances during the past generation have improved the clinician’s armamentarium in the medical and surgical management of this problem. The purpose of this article is to review the current literature regarding the pragmatic use of three of the most commonly used advanced therapies: bioengineered tissue, negative-pressure wound therapy, and hyperbaric oxygen therapy, with a focus on the near-term future of wound healing, including stem cell therapy. (J Am Podiatr Med Assoc 100(5): 385–394, 2010)
Because neuroischemic complications are associated with a high rate of recurrence, we propose a slight shift in the mechanism by which we counsel and communicate risk daily with our patients. If the epidemiology of this problem is comparable with that of cancer, and recurrences are common, then perhaps language commensurate with such risks should follow. After initial healing of an index wound, our unit now refers to patients not as being cured but rather as being “in remission.” This concept is easy for the patient and the rest of the team to understand. We believe that it powerfully connotes the necessity for frequent follow-up and rapid intervention for inevitable minor and sometimes major complications. (J Am Podiatr Med Assoc 103(2): 161–162, 2013)
Background: Exercise has not been studied extensively in persons with active neuropathic diabetic foot wounds, primarily because a device does not exist that allows patients to exercise while sufficiently off-loading pressure at the ulcer site. The purpose of this project was to demonstrate a device that reduces cycling plantar forefoot pressure.
Methods: Ten healthy participants rode a recumbent bicycle under three cycling conditions. While the left foot interaction remained constant with a standard gym shoe and pedal, the right foot was exposed to a control condition with standard gym shoe and pedal, gym shoe and specialized cleat, and gym shoe with an off-loading insole and specialized cleat. Pressure and contact area of the plantar aspect of the feet were recorded for a 10-sec interval once during each minute of each condition’s 7-min trial.
Results: The off-loading insole and specialized cleat condition yielded significantly lower (P < .01) peak pressure, contact area, and pressure–time integral values in the forefoot than the specialized cleat condition with gym shoe, which yielded significantly lower values (P < .01) than the standard gym shoe and pedal.
Conclusion: Modifications to footwear may alter plantar forefoot pressures, contact area, and pressure–time integrals while cycling. The CLEAR Cleat could play a significant role in the facilitation of fitness in patients with (or at high risk for) neuropathic wounds. (J Am Podiatr Med Assoc 98(4): 261–267, 2008)
The coronavirus disease of 2019 pandemic is driving significant change in the health-care system and disrupting the best practices for diabetic limb preservation, leaving large numbers of patients without care. Patients with diabetes and foot ulcers are at increased risk for infections, hospitalization, amputations, and death. Podiatric care is associated with fewer diabetes-related amputations, emergency room visits, hospitalizations, length-of-stay, and costs. However, podiatrists must mobilize and adopt the new paradigm of shifts away from hospital care to community-based care. Implementing the proposed Pandemic Diabetic Foot Triage System, in-home visits, higher acuity office visits, telemedicine, and remote patient monitoring can help podiatrists manage patients while reducing the coronavirus disease of 2019 risk. The goal of podiatrists during the pandemic is to reduce the burden on the health-care system by keeping diabetic foot and wound patients safe, functional, and at home.
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.
We aimed to evaluate surrogate markers commonly used in the literature for diabetic foot osteomyelitis remission after initial treatment for diabetic foot infections (DFIs).
Thirty-five patients with DFIs were prospectively enrolled and followed for 12 months. Osteomyelitis was determined from bone culture and histologic analysis initially and for recurrence. Fisher exact and χ2 tests were used for dichotomous variables and Student t and Mann-Whitney U tests for continuous variables (α = .05).
Twenty-four patients were diagnosed as having osteomyelitis and 11 as having soft-tissue infections. Four patients (16.7%) with osteomyelitis had reinfection based on bone biopsy. The success of osteomyelitis treatment varied based on the surrogate marker used to define remission: osteomyelitis infection (16.7%), failed wound healing (8.3%), reulceration (20.8%), readmission (16.7%), amputation (12.5%). There was no difference in outcomes among patients who were initially diagnosed as having osteomyelitis versus soft-tissue infections. There were no differences in osteomyelitis reinfection (16.7% versus 45.5%; P = .07), wounds that failed to heal (8.3% versus 9.1%; P = .94), reulceration (20.8% versus 27.3%; P = .67), readmission for DFIs at the same site (16.7% versus 36.4%; P = .20), amputation at the same site after discharge (12.5% versus 36.4%; P = .10). Osteomyelitis at the index site based on bone biopsy indicated that failed therapy was 16.7%. Indirect markers demonstrated a failure rate of 8.3% to 20.8%.
Most osteomyelitis markers were similar to markers in soft-tissue infection. Commonly reported surrogate markers were not shown to be specific to identify patients who failed osteomyelitis treatment compared with patients with soft-tissue infections. Given this, these surrogate markers are not reliable for use in practice to identify osteomyelitis treatment failure.
Diabetic foot wounds remain a significant health-care issue. Healing these wounds in a timely manner is of paramount importance because the duration of ulceration correlates with increased rates of infection and amputation, costing billions of dollars yearly. Collagen-based matrices have been used as wound covers and have been shown to improve and expedite healing. We present our experience with equine pericardium biomatrix for the treatment of neuropathic foot wounds.
Thirty-four patients with 37 diabetic foot wounds were evaluated at two institutions prospectively. All of the wounds were debrided, and equine pericardium biomatrix was applied. Secondary dressings were changed every 48 to 72 hours until healed or for 12 weeks after application. Healing rate at 12 weeks, time to wound closure, and complications were evaluated.
Twenty-two men and 12 women (mean age, 56.9 years) were treated and evaluated. Mean and median wound sizes at initial treatment were 715.8 and 440 mm2, respectively. The overall wound healing rate by 12 weeks was 75.7% (n =28). Mean and median times to wound closure were 7.2 and 7.0 weeks, respectively. No device or procedure-related complications were reported.
The use of equine pericardium as a temporary biological scaffold is safe and effective for the treatment of chronic neuropathic foot wounds. (J Am Podiatr Med Assoc 102(5): 352–358, 2012)