Disease Knowledge and Behavior Regarding Diabetic Foot Among Persons at Different Risks of Foot Ulceration According to the International Working Group Guidelines.

BACKGROUND: This article aims to analyze levels of knowledge and behavior about diabetic foot care and prevention in persons with diabetes according to International Working Group (IWGDF) risk stratification system. METHODS: A descriptive study in 83 persons with diabetes at different level of risk for foot ulceration (IWGDF risk 0-3). A previously validated questionnaire, the PIN Questionnaire, was used to analyze their levels of understanding of foot complications. Participants were responded on a 5-point Likert scale. RESULTS: IWGDF-3 risk patients knew that good circulation and absence of polyneuropathy in their feet were related to healthy feet relative to the other groups (19.6 ± 2.7, p<.001 and 14.2 ± 0.7, p<.001 respectively). Additionally, they knew that a foot ulcer (DFU) on their feet will not be painful relative to other groups (6.6 ± 2.8, p<.001). High-risk patients knew which physical causes could affect the development of a DFU (18 ± 1.4, p<.001) and that foot self-care and medical control could prevent DFU appearance (23.4 ± 2.15, p<.001 and 13.9 ± 0.9, p<.001 respectively). CONCLUSION: IWGDF-3 patients knew the natural progression of diabetes foot complications and how to prevent them. Clinicians should focus their efforts and educate diabetes at lower risk of foot ulcer.

Evaluation of usability, adherence, and clinical efficacy of therapeutic footwear in persons with diabetes at moderate to high risk of diabetic foot ulcers: A multicenter prospective study.

OBJECTIVE: To evaluate therapeutic footwear expectations and usability of individuals with diabetes and foot complications. DESIGN: A prospective multicenter study was conducted on participants with a high risk of developing a diabetic foot ulcer. SETTING: Participants were enrolled in 11 different specialized diabetic foot units in Spain between March 2022 and June 2023. SUBJECTS: Patients with diabetes at moderate to high risk of foot ulceration receiving first therapeutic footwear prescription. INTERVENTIONS: All the patients included in the research were prescribed with their first pair of therapeutic footwear. MAIN MEASURES: Primary outcome measures were MOS-pre and MOS-post questionnaires evaluating use and usability of prescribed therapeutic footwear. Secondary outcome measures aimed to evaluate footwear clinical efficacy as ulceration rate and self-reported perceived walking distance per day. RESULTS: The use of therapeutic footwear exceeded the patient's pre-provision prediction of their anticipated use in 94% of people (n = 126). Based on the visual analogic satisfaction scale, the median satisfaction of daily wearing their therapeutic footwear was 7 points, Interquartile Range (IQR) [5-8.25]. During the follow-up period, 39 participants (29.1%) experienced diabetic foot ulcer. Perceived walking distance participants reported an improvement in their perceived walking ability during various daily life activities. CONCLUSIONS: Diabetes patients at moderate to high risk of diabetic foot ulcer improved their perception of walking ability after therapeutic footwear prescription. Adherence to the therapeutic footwear prescription resulted in less ulcerations.

Health-related quality of life among Spanish patients with diabetic foot ulcer according to Diabetic Foot Ulcer Scale - Short Form.

AIM: The aim of this study was to investigate the health-related quality of life of Spanish outpatients with diabetic foot ulcer using the Diabetic Foot Scale-Short Form (DFS-SF). MATERIALS AND METHODS: This cross-sectional observational study included 141 outpatients with diabetic foot ulcers (DFU). The DFS-SF was applied in personal interviews conducted by a trained investigator to assess health-related quality of life (HRQoL). RESULTS: The domain related to "worried about ulcers" had the lowest in score [50 (27.5-65.0)], and the highest score was in the physical health domain [76 (60.0-88.0)]. There was a statistically significant difference in the ulcer type and the physical health subscale, finding the lowest values in the physical health subscale in patients with ischaemic diabetic foot ulcers [58 (39.0-70.0), p = 0.007]. In the multivariable analysis the domains Leisure (OR 0.98, 95% CI 0.97-0.99) and worried about ulcers/feet (OR 0.98, 95% CI 0.96-0.99) were identified as significant independent domains in patients with the experience of a previous minor amputation. A significant negative correlation was observed between the SINBAD DFU score and leisure (r = -0.181, p = 0.032), physical health (r = -0.202, p = 0.016), dependence/daily life (r = -0.232, p = 0.006), and the "bothered by ulcer care" (r = -0.239, p = 0.004) domains of the DFS-SF. The ulcer duration had a significant negative correlation with all the domains of DFS-SF. CONCLUSION: The DFS-SF survey is a specific instrument that could be implemented in diabetic foot units as part of the management of patients with DFU to evaluate HRQoL. The domain of "worried about ulcers" had the lowest score in our population suggesting that clinicians should try to work on the emotional state of patients with DFU. The mean duration of DFU was the most influential factor related to worse scores followed by previous amputations. The SINBAD score had significant negative correlations suggesting that HRQoL may be related to the severity of DFU in this study population.

Diagnostic Performance of Ultrasonography for Diabetic Foot Osteomyelitis.

Objective: This study aims to analyze the potential diagnostic capability of ultrasonography (US) in detecting diabetic foot osteomyelitis (DFO) in patients with diabetic foot ulcers (DFUs). Approach: A 1-year prospective study was conducted on 47 consecutive patients with active DFUs and suspicion of DFO at a specialized diabetic foot unit. The following ultrasonographic features were evaluated at baseline: (1) periosteal reaction; (2) periosteal elevation; (3) cortical disruption; (4) sequestrum; and (5) positive power Doppler. The primary outcome measure aimed to establish the effectiveness of ultrasonographic features compared with aseptic bone culture for diagnosing DFO. Receiver operating characteristic (ROC) curves were utilized to evaluate the diagnostic performance of ultrasonographic features. Sample size could not be determined as it is the first study to assess ultrasonographic features for the diagnosis of DFO. The research adhered to the guidelines for diagnostic accuracy studies (Standards for Reporting of Diagnostic Accuracy Studies [STARD] 2015). Results: All patients (n = 24) diagnosed with DFO exhibited positive power Doppler, resulting in a sensitivity (S) and specificity (SP) of 1 and an area under the curve (AUC) of 1 (p < 0.001 [1-1]). Cortical disruption was present in 23 patients (95.8%) with DFO, yielding an S of 0.93, SP of 1, and AUC of 0.96 (p < 0.001 [0.88-1]). Innovation: It validates the diagnostic value of US for DFO as it is the first and largest study of its kind to establish a clear reference standard to guide clinician decision-making. Conclusion: This study demonstrates the effectiveness of cortical disruption and positive power Doppler in assessing DFO through US.

Analyses of transcutaneous oxygen pressure values stratified for foot angiosomes to predict diabetic foot ulcer healing.

AIMS: Previous research suggested that diabetic foot ulcer (DFU) location could affect transcutaneous oxygen pressure (TcPO2) values following the angiosome concept. Up to our knowledge no studies have yet analyzed if the location of a diabetic foot ulcer can be a confounding factor that modifies TcPO2 values. The primary aim of this study was to compare the potential healing prognosis of TcPO2 differentiated for diabetic foot ulcers in different angiosome locations. METHODS: a 2-years observational cohort prospective study was performed in 81 patients with diabetic foot ulcers. Transcutaneous oxygen pressure measurements were performed at baseline by placing the electrode on two different angiosomes: dorsal zone of the foot (dorsalis pedis angiosome) and between the navicular bone and the tibial malleolus (posterior tibial angiosome). The main outcome was establishing the effectiveness of TcPO2 measurements (dorsalis pedis angiosome and posterior tibial angiosome) for predicting DFU healing. RESULTS: Transcutaneous oxygen pressure probe placed in the dorsum of the foot (dorsalis pedis angiosome) yielded a sensitivity (S) of 95 % and specificity (SP) of 73 %, and an area under the curve (AUC) of 0.902 (p < 0.001 [0.84-0.96]) for ulcers located in the forefoot and toes; while TcPO2 placed in the posterior tibial angiosome yielded an S of 100 % and SP of 85 % and an AUC of 0.894 (p < 0.001 [0-822-0.966]) for DFU located in the midfoot and heel. CONCLUSION: This study suggests that angiosome-guided TcPO2 contributes to a prognosis of successful foot ulcer healing.

Usability of Different Methods to Assess and Improve Adherence to Therapeutic Footwear in Persons with the Diabetic Foot in Remission. A Systematic Review.

Therapeutic footwear (TF) has been demonstrated to decrease the rate of recurrence in patients in remission. TF adherence determines the real effect of such treatment and, therefore, an appropriate evaluation of TF adherence is critical to decrease recurrence. The aim of this systematic review was to determine the usability of different methods of assessing adherence to TF in patients with diabetic foot ulcers under remission. The search strategy retrieved 506 articles. Title and abstract review excluded 472, while the full-text review excluded an additional 18 articles because the included data did not meet the selection criteria. Finally, we included 16 articles in this systematic review. Six (37.5%) of the 16 studies combined objective (OM) and subjective methods (SM). Only five (31.25%) evaluated OM and six (37.5%) studies only evaluated SM. Objective methods (temperature sensor, activity monitor) and subjective methods (survey, questionnaire) have successfully been used in the literature to evaluate TF adherence. Objective methods provided accurate data, whereas subjective methods led to response bias or missing data. Methods of evaluation showed that patients use the TF more frequently outdoors and on weekdays than indoors or on the weekend. In conclusion, objective methods are the most usable way to measure adherence to TF.

Punch Grafting for the Management of Hard-to-Heal Diabetic Foot Ulcers: A Prospective Case Series.

Punch grafting is an alternative treatment to enhance wound healing which has been associated with promising clinical outcomes in various leg and foot wound types. We aimed to evaluate the clinical outcomes of punch grafting as a treatment for hard-to-heal diabetic foot ulcers (DFUs). Six patients with chronic neuropathic or neuroischemic DFUs with more than 6 months of evolution not responding to conventional treatment were included in a prospective case series between May 2017 and December 2020. All patients were previously debrided using an ultrasound-assisted wound debridement and then, grafted with 4 to 6 mm punch from the donor site that was in all cases the anterolateral aspect of the thigh. All patients were followed up weekly until wound healing. Four (66.7%) DFUs were located in the heel, 1 (16.7%) in the dorsal aspect of the foot and 1 (16.7%) in the Achilles tendon. The median evolution time was 172 (interquartile range [IQR], 25th-75th; 44-276) weeks with a median area of 5.9 (IQR; 1.87-37.12) cm2 before grafting. Complete epithelization was achieved in 3 (50%) patients at 12 weeks follow-up period with a mean time of 5.67 ± 2.88 weeks. Two of the remaining patients achieved wound healing at 32 and 24 weeks, respectively, and 1 patient showed punch graft unsuccessful in adhering. The median time of wound healing of all patients included in the study was 9.00 (IQR; 4.00-28.00) weeks. The wound area reduction (WAR) at 4 weeks was 38.66% and WAR at 12 weeks was 88.56%. No adverse effects related to the ulcer were registered through the follow-up period. Autologous punch graft is an easy procedure that promotes healing, achieving wound closure in chronic DFUs representing an alternative of treatment for hard-to-heal DFUs in which conservative treatment has been unsuccessful.

Culture Concordance in Different Sections of the Metatarsal Head: Interpretations of Microbiological Results.

Microbiological cultures of per-wound bone biopsies have shown a lack of correlation and a high rate of false-negative results when compared with bone biopsy cultures in diabetic foot osteomyelitis. The selection of samples from the area of active osteomyelitis, which contains a complete census of the microorganisms responsible for the infection, is essential to properly guide antimicrobial treatment. We aimed to comparatively evaluate the quantitative and qualitative cultures taken from different areas, in metatarsal heads resected for osteomyelitis. For this purpose, we consecutively selected 13 metatarsal heads from 12 outpatients with plantar ulcers admitted to our diabetic foot unit. Metatarsal heads were divided transversally into 3 portions: plantar (A), central (B), and dorsal (C), and the 39 resulting samples were cultured. Qualitative and quantitative microbiological analysis was performed, and the isolated species and bacterial load, total and species specific, were compared between the 3 metatarsal bone segments. The primary outcome of the study was the bacterial diversity detected in the different bone sections. Cultures were positive in 12 of the 13 included metatarsal heads (92%). A total of 34 organisms were isolated from all specimens. Ten of the 12 cultures (83%) were polymicrobial. Ten of the 13 metatarsal heads (77%) had identical microbiological results in each of the 3 bone sections. The largest number of microorganisms was found in the central section. The overall concordance between sections was 91%. The predominant microorganisms were coagulase-negative staphylococci (41%). Statistical differences were not found in the bioburden between sections (range 3.25-3.41 log10 colony-forming unit/g for all sections; P = .511). The results of our study suggest that microorganisms exhibit a high tendency to spread along the metatarsal bone and that the degree of progression along the bone is species dependent. The central portions of metatarsal bones tend to accumulate a higher diversity of species. Thus, we recommend this area of bone for targeted biopsy in patients with suspected osteomyelitis.

Diabetic Capital Punishment: Time for Amnesty.

A study has shown that 19-34% of patients with diabetes will develop a foot ulcer in their lifetime [...].

Clinical Efficacy of a 3D Foot Scanner app for the Fitting of Therapeutic Footwear in Persons with Diabetes in Remission: A Randomized and Controlled Clinical Trial.

To evaluate the ability of high-risk patients with diabetes in remission to select proper therapeutic footwear (TF) and validate a novel 3D foot scanner app for selecting the proper fitting TF. We conducted a randomized and controlled clinical trial enrolling 30 patients with a previously healed diabetic foot ulcer carried out in a specialized diabetic foot unit between November 2021 and June 2022. All patients were recommended to TF with extra depth volume and rocker sole. The control group could acquire the TF size and model according to aesthetic preferences, while the experimental group had to acquire a specific size and model according to the result of a novel mobile app 3D feet scan. TF was recommended to change when the ill-fitting reasons were found, excessive length or tightness or compromise with toes. The primary outcome measure was the requirement of TF change after prescription because of ill-fitting. A total of seven patients required TF change, one of them (6.7%) in the experimental group and six patients (40%) in the control group (p = .031, 95% CI [0.011-1.04]). Reasons for ill-fitting were as follows: four patients due to excessive length and three patients due to toe compromise. The relative risk reduction for the need to change the TF via the foot scan compared to the control group was 83%, and the number needed to treat was 20. High-risk patients with diabetes tend to select TF with inadequate fitting (length or capacity), and they should be guided hand to hand to acquire proper TF.

Safety and Efficacy of Several Versus Isolated Prophylactic Flexor Tenotomies in Diabetes Patients: A 1-Year Prospective Study.

Background: To assess long-term clinical outcomes of patients who underwent isolated versus several percutaneous flexor tenotomies for the treatment of toe deformities and previous diabetic foot ulcers; Methods: Twenty-three patients (mean age 66.26 ± 11.20, years) who underwent prophylactic percutaneous flexor tenotomies secondary to tip-toe ulcers participated in this 1-year prospective study. The study was stratified into two groups for analyses: (1) isolated tenotomies patients, and (2) several tenotomies patients (two or more tenotomies). Outcome measures were toe reulceration and recurrence, minor lesions, digital deformities, and peak plantar pressure (PPP­N/cm2) and pressure/time Integral (PTI­N/cm2/s) in the hallux and minor toes after a 1-year follow-up period; Results: Patients with isolated tenotomies (n = 11, 35.48%) showed a higher rate of reulceration (n = 8, 72.7%, p < 0.001) in the adjacent toes, additionally, we found more prevalence of hyperkeratosis (n = 11, 100%), minor lesions (n = 9, 81%), and claw toes (n = 11, 100%) (p < 0.001). In several tenotomies patients (n = 20, 64.52%), we found a higher rate of floating toes (n = 16, 80%) in comparison with isolated tenotomies patients (p < 0.001). PPP and PTI in the non-tenotomy toes were higher in the group of patients who underwent isolated tenotomies (p < 0.001); Conclusions: Patients who underwent several tenotomies had better clinical outcomes after a 1-year follow-up period compared to isolated tenotomies.

Could X-ray Predict Long-term Complications in Patients with Diabetic Foot Osteomyelitis?

OBJECTIVE: To analyze the association between radiologic changes on plain X-rays in patients with diabetic foot osteomyelitis and the development of complications at the 1-year follow-up. METHODS: A prospective, observational study was conducted involving 115 patients with diabetic foot osteomyelitis. X-ray features that were evaluated during 1-year follow-up visits included affected bone marrow, active periosteal reaction, sequestrum, cortical disruption, and other types of signs. Researchers analyzed the association between the presence of X-ray changes and complication development, such as bone or soft tissue infections, ulcer recurrence, reulceration, amputation, death, and other diabetic foot disease-related events. RESULTS: During follow-up, of 115 patients included in the study, 33 patients (28.7%) showed radiologic changes, and 85 (73.9%) developed complications. The presence of radiologic changes after ulcer healing had a significant association with complication development during the 1-year follow-up in addition to those found at different follow-up visits. Patients who showed radiologic changes had higher percentages of complications during the 1-year follow-up, and patients without radiologic changes had lower percentages of complications. CONCLUSIONS: The presence of radiologic changes is related to the development of complications in patients who suffer from diabetic foot osteomyelitis.

Effects of wear and tear of therapeutic footwear in patients remission. A 5-year follow-up study.

AIMS: To assesses the relationship between the wear and tear of therapeutic footwear (TF) and the risk of recurrence in diabetes remission patients. METHODS: Remission patients (N = 115) participated in this 5-year prospective study in a specialized Diabetic Foot Unit between October 2016 and January 2022. Patients' TF was assessed in a three-month interval from Day 0 until ulcer recurrence was found. Primary outcome measure was based on the recurrent event in the forefoot. RESULTS: A total of 82 patients (71.3%) renewed their TF, and 33 patients (28.7%) did not renew their TF during the follow-up period. Patients who failed to renew their TF group experienced more recurrent events (22 vs 14, p <.001, CI [0.04-0.259]) and minor amputations (11 vs 8, p =.002, CI [0.07-0.6]). Both groups showed different recurrence-free survival median times of 205.5 [Interquartile range (IQR) - 188-222] weeks and 89.9 [IQR - 53-126] weeks. Patients who did not renew their TF increased their risk of suffering from a recurrent event in the Cox regression model (p <.001, CI [0.03-0.38], Hazzard Ratio 0.147). CONCLUSIONS: Patients who renewed their TF because of wear and tear experienced lower recurrences and minor amputations.

Effectiveness of the Fixtoe Device® in plantar pressure reduction: a preliminary study.

BACKGROUND: Metatarsalgia is a common foot condition. The metatarsophalangeal stabilizing taping technique described by Yu et al. has shown good clinical results as a provisional treatment in propulsive metatarsalgia. 35 The Fixtoe Device®, a novel orthopedic device, intends to simulate stabilizing tape. However, to date, there is no evidence of its effectiveness. The aim of this study was to assess plantar pressure changes using the Fixtoe Device®, in comparison with the traditional method (stabilizing tape) in a young, healthy sample thorough a cross-sectional study. METHODS: Maximal pressure (Kpa) and pressure-time integral (Kpa/s) in the second metatarsal head were measured in twenty-four healthy volunteers. Registers were taken in four different conditions: barefoot, traditional stabilizing tape, Fixtoe Device® without metatarsal pad, and Fixtoe Device® with metatarsal pad. RESULTS: Mean second metatarsal head maximal pressure and mean pressure-time integral showed statistical difference among the four analyzed conditions (p < 0.0001 in both cases). The improvement in maximal pressure and pressure-time integral obtained in each intervention also showed significance (p < 0.0001 in both cases). Comparing the improvement of the Fixtoe Device® with and without metatarsal pad with that of tape condition showed a moderate to high and moderate effect size for both peak pressure and pressure-time integral reduction. CONCLUSIONS: The Fixtoe Device® reduces median maximal pressure and median pressure-time integral under the second metatarsal head in healthy young individuals. The Fixtoe Device® shows higher effectiveness than the traditional second metatarsophalangeal joint stabilizing taping technique. To our knowledge, this is the first investigation proving the effectiveness of the recently developed Fixtoe Device® in terms of plantar pressure modification, which leads the way to its use in clinics.

Comparative Clinical Outcomes of Patients with Diabetic Foot Infection Caused by Methicillin-Resistant Staphylococcus Aureus (MRSA) or Methicillin-Sensitive Staphylococcus Aureus (MSSA).

Few studies have addressed the interaction of specific pathogens with clinical outcomes in patients with diabetic foot infection (DFI). Our study aim was to compare the clinical outcomes among patients with DFI caused by methicillin-resistant Staphylococcus aureus (MRSA) with cases caused by methicillin-sensitive Staphylococcus aureus (MSSA). We gathered the data of 75 consecutive patients admitted at specialized outpatients diabetic with mild or moderate DFI in which S. aureus was isolated from bone or soft tissue specimens in pure or as a part of the polymicrobial culture. Patients were divided into two groups: those with MRSA infection and those with MSSA infection. Patients with MRSA diabetic foot infections were significantly associated with male gender (86% vs. 64%, P = .029), higher SINBAD Classification Score (3.6 ± 0.99 points vs. 2.8 ± 1.06 points, P = .001), longer mean wound evolution [17.8 (3;29.5) weeks versus 9.1 (1;12) weeks, P = .008], bone involvement [18 (50%) versus 9 (23.1%), P = .015] and longer mean healing time [18.2(8;28) weeks versus 9.1 (1;12) weeks, P = .008]. In addition, male gender (OR 8.81, 95% CI 2.00-38.84) and SINBAD Classification Score (OR 2.70, 1.46-5.00) were identified as independent risk factors for MRSA DFI. Significant differences in the number of surgical procedures to resolve infection [15 (41.7%) versus 13 (33.3%), P = .456] or in the mean healing time after surgical treatment [10.5 weeks (6.7;16.5) versus 6.1 weeks (3;8.7), P = .068] were not observed among groups, suggesting that when treatment is based on early and surgical debridement, MRSA infections are not associated with worse prognosis. In conclusion MRSA DFI has importance in clinical outcomes such as time to healing. We propose that recent lines of research regarding the genetic virulence of strains of S. aureus could provide new insights into our results.

Predictive Radiographic Values for Foot Ulceration in Persons with Charcot Foot Divided by Lateral or Medial Midfoot Deformity.

BACKGROUND: To identify differences in radiographic outcomes in weight-bearing lateral X-ray to predict the probability of ulceration in patients with midfoot Charcot neuroarthropathy (CN) differentiated by lateral and medial column deformities. METHODS: Thirty-five patients who suffered from CN midfoot deformity participated in this 1 year prospective study in a specialized diabetic foot unit. Lateral talar-first metatarsal angle, calcaneal pitch, and cuboid height were performed by digital radiographs in the weight-bearing lateral view. Patients were followed up for 1 year or until an ulcer ulceration event occurred in the midfoot region. RESULTS: ROC analyses showed that all patients with medial pattern deformity that developed a midfoot ulcer had a lateral talar-first metatarsal angle greater (negative) than -27.5 degrees (°). All patients with lateral pattern deformity that developed a midfoot ulcer had a calcaneal pitch greater (more negative) than -5° and a cuboid height greater (more negative) than -1.5°. CONCLUSIONS: Lateral talar-first metatarsal angle was the greatest predictor of midfoot ulceration, with greater than -27.5° measurement correlating with ulceration occurrence in patients with medial deformity. Calcaneal pitch and cuboid height were the greatest predictors of midfoot ulceration with greater than -5 and -1.5°, respectively in patients with CN lateral deformity.

A comparison of hyperspectral imaging with routine vascular noninvasive techniques to assess the healing prognosis in patients with diabetic foot ulcers.

OBJECTIVE: To compare the potential healing prognosis of the different routine noninvasive techniques implemented in the International Working Group Diabetic Foot Guidelines with the novel use of hyperspectral imaging (HSI) in patients with diabetic foot ulcers (DFUs). METHODS: Twenty-one patients with active DFUs participated in this 1-year prospective study in a specialized diabetic foot unit between December 2018 and January 2020. HSI was performed at baseline to quantify tissue oxygenation and should be presented on an anatomical map by analyzing the following parameters: (1) oxygen saturation of the hemoglobin, (2) tissue hemoglobin index, (3) the near-infrared perfusion index, and (4) tissue water index. In addition, transcutaneous oxygen pressure (TcpO2), systolic toe and ankle pressures, ankle-brachial index, and toe-brachial index values were calculated for the ulcerated limb. The primary outcome measure was wound healing, defined as complete epithelization without any drainage confirmed for at least 10 days after closure was first documented at 24 weeks. RESULTS: During the follow-up period 14 patients (66.66 %) healed and 7 patients did not heal (33.3%) by 24 weeks. The TcpO2 optimal cut-off point as determined by a balance of sensitivity and specificity of 28.5 mm Hg that yielded a sensitivity of 91% and a specificity of 100%, and area under the curve of 0.989 (P = .005; 95% confidence interval [CI], 0.945-1.000). Followed by the oxygen saturation of the hemoglobin optimal cut-off point as determined by a balance of sensitivity and specificity of 48.5 mm Hg that yielded a sensitivity of 93% and a specificity of 0.71%, and area under the curve of 0.932 (P = .013; 95% CI, 0.787-1.000). The logistic regression analyses showed that TcpO2 was the only variable associated with wound healing at 24 weeks (P < .001; 95% CI, 0.046-0.642). CONCLUSIONS: The HSI was shown to be effective in the prognosis of DFU healing compared with other noninvasive test; only TcpO2 values resulted in better diagnosis potential in wound healing.

The Influence of Multidrug-Resistant Bacteria on Clinical Outcomes of Diabetic Foot Ulcers: A Systematic Review.

Multidrug-resistant organism infections have become important in recent years due to the increased prevalence of diabetic foot ulcers and their possible consequences. This study aimed to systematically review and evaluate ulcer duration, healing time, hospital stay, amputation, and mortality rates in patients with diabetic foot ulcers caused by infection with multidrug-resistant organisms. PubMed, the Cochrane Library, and Web of Science were searched in May 2020 to find observational studies in English about the clinical outcomes of multidrug-resistant organism infection in diabetic foot ulcers. Eight studies met the inclusion criteria, and these studies included 923 patients. The overall methodological quality of the study was moderate. Ulcer duration was described in six studies, and there was no practical association with multidrug-resistant organisms. Two out of three studies reported a longer healing time in multidrug-resistant organism infections than in non-multidrug-resistant organism infections. Clinical outcomes included the duration of hospitalisation, surgeries, amputations, and deaths. Lower limb amputation was the most reported clinical outcome in the included studies, and was more prevalent in the multidrug-resistant organism infections. We concluded that there was not enough evidence that multidrug-resistant organisms hindered the healing of diabetic foot ulcers. In contrast to the clinical outcomes, multidrug-resistant organisms affect both amputation rates and mortality rates.

Predictive values of foot plantar pressure assessment in patients with midfoot deformity secondary to Charcot neuroarthropathy.

AIMS: The principal aim of this study was to identify a cut-off point along the spectrum of peak plantar midfoot pressure that has an optimum combination of sensitivity and specificity to screen for neuropathic ulceration in patients with Charcot neuroarthropathy (CN). METHODS: A 1-year outcome study was performed in twenty-five patients with diabetes, affected with chronic CN midfoot deformity. Peak plantar pressure (PPP) and pressure/time Integral (PTI) in the midfoot region were registered. For selecting the optimal diagnostic cut-off points on the scale of pressure measurement, ROC curves were used. RESULTS: Twelve (48%) patients developed a plantar midfoot ulcer. Baseline PPP (24.04 ± 6.33 Vs. 12.85 ± 3.29 N/cm2) and PTI (11.89 ± 4.60 Vs. 5.42 ± 2.26 N/cm2/s) were significantly higher in the ulcerated group (p < .001 and p < .001, respectively). Using ROC analyses, optimal cut-off point for PPP was 16.45 N/cm2, yielding a sensitivity of 92% and a specificity of 85%; and for PTI, optimal cut-off point was 7.2 N/cm2/s, yielding a sensitivity of 92% and a specificity of 77%. CONCLUSIONS: Patients with CN midfoot deformity with cut-off values for PPP of 16.45 N/cm2 and PTI of 7.2 N/cm2/s showed an elevated risk of neuropathic ulceration in the plantar area of the midfoot.

Diagnostic Accuracy of Bone Culture Versus Biopsy in Diabetic Foot Osteomyelitis.

OBJECTIVE: To compare the diagnostic accuracy of bone culture (microbiology) and biopsy (histology) in patients with acute or chronic diabetic foot osteomyelitis (DFO). METHODS: This cross-sectional study involved patients for whom providers had a clinical suspicion of DFO. Two bone samples were taken: one for microbiologic testing and another for histologic testing. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio were calculated for bone culture results in relation to the probability of DFO diagnosis. RESULTS: Fifty-two patients were included; 69% had positive bone culture results, and 90.4% had positive histology results (P = .013), and of those 90.4%, 25.5% had acute and 74.5% had chronic DFO. The sensitivity of the microbiologic bone culture result was 0.70, the specificity was 0.40, the positive predictive value was 0.92, and the negative predictive value was 0.13. CONCLUSIONS: Histology provides more accurate diagnosis of DFO than microbiology, especially for patients with chronic DFO. These patients could be underdiagnosed because of false-negative results provided by bone culture. Providers should perform both tests to confirm the presence of DFO.