Diabetic foot ulcers: weekly versus second-weekly conservative sharp wound debridement.

Diabetic foot ulcers (DFU) are a serious and costly long-term complication of diabetes, and are one of the most prevalent hard-to-heal (chronic) wound types. Conservative sharp wound debridement (CSWD) is a mainstay of care. It is performed regularly until healing is achieved (when there is adequate blood flow for healing) to support endogenous healing and improve the efficacy of advanced healing therapies. CSWD is supported by evidence-based treatment guidelines, despite a lack of prospective studies. The first prospective randomised study to compare different frequencies of CSWD-the Diabetes Debridement Study (DDS)-showed no difference in healing outcomes at 12 weeks between those ulcers debrided weekly and those debrided every second week. A DFU may require more or less frequent debridement according to individual wound characteristics; however, the new data from DDS can inform clinical decisions and service provision. The implications of weekly versus second-weekly debridement are discussed.

Timing of minor and major amputation in patients with diabetes-related foot ulceration admitted to two public tertiary referral hospitals in Australia.

BACKGROUND: There is limited information regarding the number of patients with diabetes-related foot ulceration (DFU) who receive minor or major amputation, and how quickly these amputations occur. This study aimed to identify the incidence of index minor and major amputation among inpatients with DFU over 4 years, and where amputation occurred during the patient's index DFU-related admission, investigate prognostic factors. METHODS: The incidence of index minor and major amputation, and the admission sequence during which amputation occurred were identified from DFU-related admissions to two public hospitals during 2014-2018. Where minor or major amputation occurred during the patient's index DFU-related admission, prognostic factors were investigated using logistic regression. RESULTS: DFU-related hospital admissions were required by 564 patients. The incidence of minor amputation over 4 years was 34% (n = 193). The incidence of minor amputation during the patient's index DFU-related admission was 28% (n = 155), which was associated with requiring revascularisation (odds ratio [OR] 2.33, 95% CI 1.53-3.55, P < 0.001). The incidence of major amputation over 4 years was 8% (n = 45). The incidence of major amputation during the patient's index DFU-related admission was 6% (n = 31), which was associated with having more comorbidities (OR 1.58, 95% CI 1.10-2.26, P = 0.01) and receiving care for a mental health condition (OR 3.85, 95% CI 1.48-10.01, P = 0.006). CONCLUSION: Most amputations occurred during the patient's index DFU-related hospital admission. Major amputation during a patient's index admission was associated with more comorbidities and mental health conditions.

Does in-shoe pressure analysis to assess and modify medical grade footwear improve patient adherence and understanding? A mixed methods study.

BACKGROUND: Medical grade footwear (MGF) with demonstrated plantar-pressure reducing effect is recommended to reduce the risk of diabetes-related foot ulceration (DFU). Efficacy of MGF relies on high adherence (≥ 80%). In-shoe pressure analysis (IPA) is used to assess and modify MGF, however, there is limited evidence for the impact on patient adherence and understanding of MGF. The primary aim of this study was to determine if self-reported adherence to MGF usage in patients with previous DFU improved following IPA compared to adherence measured prior. The secondary aim was to determine if patient understanding of MGF improved following in-shoe pressure analysis. METHODS: Patients with previous DFU fitted with MGF in the last 12 months were recruited. The first three participants were included in a pilot study to test procedures and questionnaires. MGF was assessed and modified at Week 0 based on findings from IPA using the Pedar system (Novel). Patients completed two questionnaires, one assessing patient adherence to MGF at Week 0 and Week 4, the other assessing patient understanding of MGF before and after IPA at week 0. Patient understanding was measured using a 5-point Likert scale (strongly disagree 1 to strongly agree 5). Patient experience was assessed via a telephone questionnaire administered between Weeks 0-1. RESULTS: Fifteen participants were recruited, and all completed the study. Adherence of ≥ 80% to MGF usage inside the home was 13.3% (n = 2) pre-IPA and 20.0% (n = 3) at Week 4. Outside the home, ≥ 80% adherence to MGF was 53.3% (n = 8) pre-IPA, and 80.0% (n = 12) at Week 4. Change in scores for understanding of MGF were small, however, all participants reported that undergoing the intervention was worthwhile and beneficial. CONCLUSIONS: Self-reported adherence inside the home demonstrated minimal improvement after 4 weeks, however, adherence of ≥ 80% outside the home increased by 27%, with 80% of all participants reporting high adherence at Week 4. Participants rated their learnings from the experience of IPA as beneficial.

Preventing diabetes-related foot ulcers through early detection of peripheral neuropathy.

BACKGROUND: Peripheral neuropathy, peripheral arterial disease and diabetes-related foot ulcers are the most important risk factors for future amputation. Up to 50% of people with diabetes have distal symmetrical polyneuropathy as a complication of diabetes. Distal symmetrical polyneuropathy results in loss of protective sensation in the feet, increasing the risk of diabetes-related foot ulceration. OBJECTIVE: The aim of this article is to provide structured guidance for detecting diabetes-related peripheral neuropathy, appropriate referral based on risk assessment and prevention of diabetes­related foot ulceration. DISCUSSION: As a result of the often-asymptomatic nature of diabetes-related peripheral neuropathy, general practice is an ideal location for screening all adults with diabetes for loss of protective sensation. Loss of protective sensation in a person with diabetes indicates an at-risk foot. Increased frequency of foot examination, education in self-care, appropriate footwear and referral to podiatry for non­ulcerative foot problems can reduce the development of diabetes-related foot ulcers.

Australian guideline on offloading treatment for foot ulcers: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease.

BACKGROUND: Pressure offloading treatment is critical for healing diabetes-related foot ulcers (DFU). Yet the 2011 Australian DFU guidelines regarding offloading treatment are outdated. A national expert panel aimed to develop a new Australian guideline on offloading treatment for people with DFU by adapting international guidelines that have been assessed as suitable to adapt to the Australian context. METHODS: National Health and Medical Research Council procedures were used to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines to the Australian context. We systematically screened, assessed and judged all IWGDF offloading recommendations using best practice ADAPTE and GRADE frameworks to decide which recommendations should be adopted, adapted or excluded in the Australian context. For each recommendation, we re-evaluated the wording, quality of evidence, strength of recommendation, and provided rationale, justifications and implementation considerations, including for geographically remote and Aboriginal and Torres Strait Islander peoples. This guideline, along with five accompanying Australian DFU guidelines, underwent public consultation, further revision and approval by ten national peak bodies (professional organisations). RESULTS: Of the 13 original IWGDF offloading treatment recommendations, we adopted four and adapted nine. The main reasons for adapting the IWGDF recommendations included differences in quality of evidence ratings and clarification of the intervention(s) and control treatment(s) in the recommendations for the Australian context. For Australians with plantar DFU, we recommend a step-down offloading treatment approach based on their contraindications and tolerance. We strongly recommend non-removable knee-high offloading devices as first-line treatment, removable knee-high offloading devices as second-line, removable ankle-high offloading devices third-line, and medical grade footwear as last-line. We recommend considering using felted foam in combination with the chosen offloading device or footwear to further reduce plantar pressure. If offloading device options fail to heal a person with plantar DFU, we recommend considering various surgical offloading procedures. For people with non-plantar DFU, depending on the type and location of the DFU, we recommend using a removable offloading device, felted foam, toe spacers or orthoses, or medical grade footwear. The six new guidelines and the full protocol can be found at: https://diabetesfeetaustralia.org/new-guidelines/ . CONCLUSIONS: We have developed a new Australian evidence-based guideline on offloading treatment for people with DFU that has been endorsed by ten key national peak bodies. Health professionals implementing these offloading recommendations in Australia should produce better DFU healing outcomes for their patients, communities, and country.

Frequency of sharp wound debridement in the management of diabetes-related foot ulcers: exploring current practice.

BACKGROUND: Conservative sharp wound debridement (CSWD) is fundamental to wound bed preparation. Evidence-based practice guidelines strongly recommend frequent CSWD of diabetes-related foot ulcers (DFU) based on expert opinion and observational studies which suggest that more frequent debridement is associated with better healing outcomes. AIM: To document current practice with regards to CSWD of DFU and whether this is performed at every visit, how often and what factors determine debridement frequency. METHOD: Survey data were collected and managed using REDCap electronic data tools, a secure, web-based application. The survey was distributed through podiatry managers and relevant clinical networks between October 2017 and February 2018. RESULTS: One hundred clinicians opened the survey and seventy-five surveys were completed by n = 53 NSW Health (Australia) employed podiatrists (representing 41% of all NSW Health podiatrists), 11 privately practicing podiatrists, and 11 nurses. Most (n = 47) worked in metropolitan areas versus regional/remote (n = 28). CSWD was the most frequently used debridement method, performed at every visit by most (84%) of podiatrists. Callus, slough and infection presence were the top 3 most important determinants of frequency, with staff time (a limiting factor) ranking 4th. Regional/remote podiatrists practiced less frequent debridement compared with those in metropolitan areas (debridement every 2 weeks or less = 71% regional podiatrists versus 45% metropolitan podiatrists) (p = 0.024). CONCLUSION AND CLINICAL IMPLICATIONS: CSWD was the predominant form of debridement used with debridement occurring at every treatment visit for most of the clinicians surveyed. Debridement frequency was determined by clinical wound indications and staffing resources, with regional/remote podiatrists providing debridement less often than their metropolitan colleagues.

Monocyte phenotype as a predictive marker for wound healing in diabetes-related foot ulcers.

AIMS: Delayed healing of diabetes-related foot ulcers (DRFUs) is associated with increased macrophage and matrix metalloproteinases (MMPs) at the wound site. Whether circulating monocyte phenotype and/or MMPs are altered in association with wound healing outcome is unknown, and was investigated in this study. METHODS: Blood was obtained from 21 participants with DRFU, at initial visit (V1), week-4 (V2), and week-8 (V3) for measurement of monocyte number (CD14+), phenotype (CD16, CD163) and chemokine receptors (CCRs) by flow cytometry, and circulating MMPs and TIMP-1 by ELISA. RESULTS: Six wounds healed during the study. At V1, non-classical CD16++ monocytes and MMP-3 were higher in healed vs unhealed (both p < 0.05). At V3, the increased %CD16++ persisted and %CCR2+ was decreased in healed, but no other monocyte markers nor MMP/TIMP differed between groups. Increased wound closure rate (WCR) at V3 correlated with increased %CD16++ monocytes and decreased MMP-2 at V1 or V1 + V2. Receiver operating characteristic (ROC) curves yielded an area-under-the-curve of %CD16++ at V1 of 0.78 to predict ulcer healing at V3. CONCLUSIONS: These results indicate that circulating monocyte phenotype and MMPs alter as DRFUs heal. The relationship of %CD16++ monocytes with WCR and ROC curve suggest a predictive role of %CD16++ monocytes for ulcer healing.

Topical application of the bee hive protectant propolis is well tolerated and improves human diabetic foot ulcer healing in a prospective feasibility study.

AIMS: Propolis is a naturally occurring anti-inflammatory bee derived protectant resin. We have previously reported that topically applied propolis reduces inflammation and improves cutaneous ulcer healing in diabetic rodents. The aim of this study was to determine if propolis shows efficacy in a pilot study of human diabetic foot ulcer (DFU) healing and if it is well tolerated. MATERIALS: Serial consenting subjects (n=24) with DFU ≥4 weeks' duration had topical propolis applied at each clinic review for 6 weeks. Post-debridement wound fluid was analyzed for viable bacterial count and pro-inflammatory MMP-9 activity. Ulcer healing data were compared with a matched control cohort of n=84 with comparable DFU treated recently at the same center. RESULTS: Ulcer area was reduced by a mean 41% in the propolis group compared with 16% in the control group at week 1 (P<0.001), and by 63 vs. 44% at week 3, respectively (P<0.05). In addition, 10 vs. 2% (P<0.001), then 19 vs. 12% (P<0.05) of propolis treated vs. control ulcers had fully healed by weeks 3 and 7, respectively. Post-debridement wound fluid active MMP-9 was significantly reduced, by 18.1 vs. 2.8% week 3 from baseline in propolis treated ulcers vs. controls (P<0.001), as were bacterial counts (P<0.001). No adverse effects from propolis were reported. CONCLUSIONS: Topical propolis is a well-tolerated therapy for wound healing and this pilot in human DFU indicates for the first time that it may enhance wound closure in this setting when applied weekly. A multi-site randomized controlled of topical propolis now appears to be warranted in diabetic foot ulcers.

Australian Diabetes Foot Network: practical guideline on the provision of footwear for people with diabetes.

Trauma, in the form of pressure and/or friction from footwear, is a common cause of foot ulceration in people with diabetes. These practical recommendations regarding the provision of footwear for people with diabetes were agreed upon following review of existing position statements and clinical guidelines. The aim of this process was not to re-invent existing guidelines but to provide practical guidance for health professionals on how they can best deliver these recommendations within the Australian health system. Where information was lacking or inconsistent, a consensus was reached following discussion by all authors. Appropriately prescribed footwear, used alone or in conjunction with custom-made foot orthoses, can reduce pedal pressures and reduce the risk of foot ulceration. It is important for all health professionals involved in the care of people with diabetes to both assess and make recommendations on the footwear needs of their clients or to refer to health professionals with such skills and knowledge. Individuals with more complex footwear needs (for example those who require custom-made medical grade footwear and orthoses) should be referred to health professionals with experience in the prescription of these modalities and who are able to provide appropriate and timely follow-up. Where financial disadvantage is a barrier to individuals acquiring appropriate footwear, health care professionals should be aware of state and territory based equipment funding schemes that can provide financial assistance. Aboriginal and Torres Strait Islanders and people living in rural and remote areas are likely to have limited access to a broad range of footwear. Provision of appropriate footwear to people with diabetes in these communities needs be addressed as part of a comprehensive national strategy to reduce the burden of diabetes and its complications on the health system.

Australian Diabetes Foot Network: management of diabetes-related foot ulceration - a clinical update.

Appropriate assessment and management of diabetes-related foot ulcers (DRFUs) is essential to reduce amputation risk. Management requires debridement, wound dressing, pressure off-loading, good glycaemic control and potentially antibiotic therapy and vascular intervention. As a minimum, all DRFUs should be managed by a doctor and a podiatrist and/or wound care nurse. Health professionals unable to provide appropriate care for people with DRFUs should promptly refer individuals to professionals with the requisite knowledge and skills. Indicators for immediate referral to an emergency department or multidisciplinary foot care team (MFCT) include gangrene, limb-threatening ischaemia, deep ulcers (bone, joint or tendon in the wound base), ascending cellulitis, systemic symptoms of infection and abscesses. Referral to an MFCT should occur if there is lack of wound progress after 4 weeks of appropriate treatment.

Increased matrix metalloproteinase-9 predicts poor wound healing in diabetic foot ulcers.

OBJECTIVE: We studied the relationships of diabetic ulcer wound fluid matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs), and transforming growth factor-beta1 (TGF-beta1) with wound healing rate. RESEARCH DESIGN AND METHODS: The ulcers were cleansed to remove exudates, and wound fluids were collected for analysis of MMP-2 and -9, TIMP-1, and TGF-beta1. RESULTS: At presentation, MMP-9 and the MMP-9-to-TIMP-1 ratio correlated inversely with the wound healing rate at 28 days (P < 0.001). MMP-9 and the MMP-9-to-TIMP-1 ratio were lower in the 23 patients who achieved complete healing at 12 weeks versus the 39 who did not. The pro-MMP-9 concentration was predictive of healing within 12 weeks. Addition of cutoffs for TIMP-1 (>480 pg/ml) and TGF-beta (>115 pg/ml) further improved its predictive power (area under the curve 0.94). CONCLUSIONS: These findings suggest that a milieu with high MMP-9 may be indicative of inflammation and poor wound healing. Measurements of MMP-9, TIMP-1, and TGF-beta in wound fluid may help to identify ulcers at risk of poor healing.

Biomechanical risk factors associated with neuropathic ulceration of the hallux in people with diabetes mellitus.

In this study of people with diabetes mellitus and peripheral neuropathy, it was found that the feet of patients with a history of hallux ulceration were more pronated and less able to complete a single-leg heel rise compared with the feet of patients with a history of ulceration elsewhere on the foot. The range of active first metatarsophalangeal joint dorsiflexion was found to be significantly lower in the affected foot. Ankle dorsiflexion, subtalar joint range of motion, and angle of gait differed from normal values but were similar to those found in other studies involving diabetic subjects and were not important factors in the occurrence of hallux ulceration. These data indicate that a more pronated foot type is associated with hallux ulceration in diabetic feet. Further studies are required to evaluate the efficacy of footwear and orthoses in altering foot posture to manage hallux ulceration.

From acute to chronic: monitoring the progress of Charcot's arthropathy.

The monitoring of Charcot's arthropathy in patients with diabetes mellitus is twofold: 1) assessment of disease activity as the condition progresses from the acute to the chronic phase, and 2) identification of structural abnormalities and complications that may arise as a result of the disease. The former guides the clinician as to the duration of primary treatment, and the latter provides important information regarding the long-term prognosis and facilitates clinical decision making regarding other treatments including surgery, footwear, and orthoses. The mainstay of assessing disease activity remains thorough and regular assessment of swelling, temperature differences, and bony abnormalities. Radiographic assessment performed at baseline and periodically throughout the course of the disease will show stages of early fracture and fragmentation followed by eventual trabecular bridging, ankylosis of the affected joints, and sclerosis, heralding the chronic phase of the disease. Radiographic assessment also provides visualization of bony deformities and prominences. In addition to these assessments, changes may be further quantified by the use of infrared dermal thermography and quantitative bone scanning techniques. Careful clinical monitoring of patients is essential to optimize treatment for acute Charcot's arthropathy and improve the long-term outcome for patients presenting with this condition.