The role of surgical off-loading to prevent recurrent ulcerations.

Foot ulcerations in patients with diabetes are common. Most ulcers heal with conservative treatment, but recurrence is common. The pathway of ulcer development includes neuropathy, deformity, and trauma. The first attempt to avoid recurrence is by the use of shoes and insoles. When shoes and insoles fail, surgical correction of deformity leading to the ulcer can be attempted. This article reviews the most common procedures performed to heal ulcers or avoid recurrence.

Negative Pressure Wound Therapy With Low Pressure and Gauze Dressings to Treat Diabetic Foot Wounds.

This study was a prospective cohort study to evaluate negative pressure wound therapy (NPWT) with low pressure and a gauze dressing to treat diabetic foot wounds. Thirty patients with diabetic foot wounds were consented to a prospective study to evaluate wound closure and complications to evaluate NPWT with low pressure (80 mmHg) and a gauze dressing interface (EZCare, Smith and Nephew) for up to 5 weeks. NPWT was changed 3 times a week. Study subjects were evaluated once a week for adverse events and wound measurements. Of study subjects, 43% attained at least a 50% wound area reduction after 4 weeks of therapy. Our results suggest that a high rate of wound closure could be expected with low pressure and a gauze interface.

Risk factors for developing osteomyelitis in patients with diabetic foot wounds.

AIMS: Osteomyelitis worsens the prognosis in the diabetic foot, but predisposing factors remain largely undefined. In a prospectively followed cohort we assessed risk factors for developing osteomyelitis. METHODS: We enrolled consecutive persons with diabetes who presented to a managed-care diabetes disease management program. The patients underwent standardized assessments. We monitored for all foot complications, defined infections by criteria consistent with International Working Group guidelines, and defined osteomyelitis as a positive culture from a bone specimen. RESULTS: 1666 persons were enrolled, 50% male, mean age 69 years. Over a mean of 27.2 months of follow-up, 151 patients developed foot infections, 30 (19.9%) of which involved bone. Independent risk factors for osteomyelitis were: wounds that extended to bone or joint (relative risk [RR]=23.1), previous history of a wound prior to enrollment (RR=2.2), and recurrent or multiple wounds during the study period (RR=1.9). CONCLUSIONS: In this study population, managed in a specialized diabetic foot care center, the results suggest that independent risk factors for developing osteomyelitis are deep, recurrent and multiple wounds. These results may help clinicians target their efforts at diagnosing foot osteomyelitis to the highest risk patients.

Reevaluating the way we classify the diabetic foot: restructuring the diabetic foot risk classification system of the International Working Group on the Diabetic Foot.

OBJECTIVE: To separately evaluate peripheral arterial occlusive disease (PAOD) and foot ulcer and amputation history in a diabetic foot risk classification to predict foot complications. RESEARCH DESIGN AND METHODS: We evaluated 1,666 diabetic patients for 27.2 +/- 4.2 months. Patients underwent a detailed foot assessment and were followed at regular intervals. We used a modified version of the International Working Group on the Diabetic Foot's (IWGDF's) risk classification to assess complications during the follow-up period. RESULTS: There were more ulcerations, infections, amputations, and hospitalizations as risk group increased (chi(2) for trend P < 0.001). When risk category 2 (neuropathy and deformity and/or PAOD) was stratified by PAOD, there were more complications in PAOD patients (P < 0.01). When risk group 3 patients (ulceration or amputation history) were separately stratified, there were more complications in subjects with previous amputation (P < 0.01). CONCLUSIONS: We propose a new risk classification that predicts future foot complications better than that currently used by the IWGDF.

Does anodyne light therapy improve peripheral neuropathy in diabetes? A double-blind, sham-controlled, randomized trial to evaluate monochromatic infrared photoenergy.

OBJECTIVE: The purpose of this study was to determine the efficacy of anodyne monochromatic infrared photo energy (MIRE) in-home treatments over a 90-day period to improve peripheral sensation and self-reported quality of life in individuals with diabetes. RESEARCH DESIGN AND METHODS: This was a double-blind, randomized, sham-controlled clinical trail. We randomly assigned 69 individuals with diabetes and a vibration perception threshold (VPT) between 20 and 45 V to two treatment groups: active or sham treatment. Sixty patients (120 limbs) completed the study. Anodyne units were used at home every day for 40 min for 90 days. We evaluated nerve conduction velocities, VPT, Semmes-Weinstein monofilaments (SWM) (4-, 10-, 26-, and 60-g monofilaments), the Michigan Neuropathy Screening Instrument (MNSI), a 10-cm visual analog pain scale, and a neuropathy-specific quality of life instrument. We used a nested repeated-measures multiple ANOVA design. Two sites (great toe and fifth metatarsal) were tested on both the left and right feet of each patient, so two feet were nested within each patient and two sites were nested within each foot. To analyze the ordinal SWM scores, we used a nonparametric factorial analysis for longitudinal data. RESULTS: There were no significant differences in measures for quality of life, MNSI, VPT, SWM, or nerve conduction velocities in active or sham treatment groups (P > 0.05). CONCLUSIONS: Anodyne MIRE therapy was no more effective than sham therapy in the treatment of sensory neuropathy in individuals with diabetes.

Validation of the Infectious Diseases Society of America's diabetic foot infection classification system.

In this longitudinal study of 1666 persons with diabetes, there was an observed trend toward an increased risk for amputation (chi(2) test for trend, 108.0; P<.001), higher-level amputation (chi(2) test for trend, 113.3; P<.001), and lower extremity-related hospitalization (chi(2) test for trend, 118.6; P<.001) with increasing infection severity. The Infectious Diseases Society of America's foot infection classification system may be a useful tool for grading foot infections.