Use of hyperspectral imaging to predict healing of diabetic foot ulceration.

Our main objective was to validate that hyperspectral imaging via a new portable camera carries the potential to provide a reliable clinical biomarker that can predict DFU healing. We recruited patients with diabetic foot ulceration (DFU) without peripheral arterial disease, infection or other serious illness. Using an hyperspectral imaging (HSI) apparatus, post-debridement hyperspectral images were taken evaluating the ulcer size, periwound oxyhemoglobin (OxyHb), deoxyhemoglobin level (DeoxyHb) and oxygen saturation (O2 Sat) for four consecutive visits. Twenty-seven patients were followed, out of whom seven healed their DFU while the remaining 20 failed to heal their DFU. The average time between each visit was 3 weeks. Binary logistic regression of healers versus non-healers on Visit 1 oxyHb and on Visit 2 showed a significant inverse association, OR = 0.85 (95% CI: 0.73-0.98, p < 0.001). An inverse correlation was observed between the Visit 1 oxyHb and the percentage of ulcer size reduction between Visit 1 and Visit 4 (r = -0.46, p = 0.02) and between the Visit 2 oxyHb and the percentage of ulcer size reduction between Visits 2 and 4 (r = -0.65, p = 0.001). Using oxyHb 50 as the cut-off point to predict DFU complete healing, Visit 1 oxyHb measurement provided 85% sensitivity, 70% specificity, 50% positive predictive value and 93% negative predictive value. For Visit 2, oxyHb had 85% sensitivity, 85% specificity, 66% positive predictive value and 94% negative predictive value. We conclude that this preliminary study, which involved a relatively small number of patients, indicates that hyperspectral imaging is a simple exam that can easily be added to daily clinical practice and has the potential to provide useful information regarding the healing potential of DFU over a short period of time.

Subtalar Arthroereisis Implantation in Acquired Neuropathic Pes Planus: A Preliminary Report Detailing a Minimally Invasive Approach to Healing Medial Column Ulcerations.

Ulcerations under the medial column in patients with acquired neuropathic pes planus may be intractable to conservative techniques such as regular debridement, offloading, bracing, and accommodative shoes. When surgery becomes necessary for these patients, the foot and ankle surgeon has the option of exostectomy, medial column beaming, medial column fusion, and external fixation, among others. In the case of a flexible midfoot collapse, the option of arthroereisis for indirect medial column support may be warranted. In this preliminary report, the authors detail a technique of Achilles tendon lengthening, arthroereisis implantation, and advanced cellular tissue product application in an attempt at wound coverage and prevention of recurrence. Three patients presenting with intractable medial column ulcerations of ∼1 year's duration underwent this procedure, and within 7 weeks (range 5 to 7), all medial column ulcerations healed. These patients remained healed at last follow-up (average 29 months; range 8 to 44). This preliminary report provides evidence for a minimally invasive procedure aimed at offloading, healing, and preventing recurrence of medial column ulcerations in patients with flexible neuropathic pes planus.

A Retrospective Case Series of a Dehydrated Amniotic Membrane Allograft for Treatment of Unresolved Diabetic Foot Ulcers.

BACKGROUND: Foot ulcers are among the most serious complications of diabetes and can lead to amputation. Diabetic foot ulcers (DFUs) often fail to heal with standard wound care, thereby making new treatments necessary. This case series describes the addition of a dehydrated amniotic membrane allograft (DAMA) to standard care in unresolved DFUs. METHODS: This is a single-center retrospective chart review of eight patients who had one to three applications of DAMA to nine DFUs that had failed to resolve despite offloading, other standard care, and adjuvant therapies. Following initial DAMA placement, wound size (length, width, depth) was measured every 1 to 2 weeks until closure. The principal outcome assessed was mean time to wound closure; other outcomes included mean percent reduction from baseline in wound area and volume at weeks 2 to 8. RESULTS: All wounds were closed a mean of 9.2 weeks after the first DAMA application (range, 3.0-13.5 weeks). Compared with baseline, wound area and volume, respectively, were reduced by a mean of 48% and 60% at week 2 and by 89% and 91% at week 8. Time to closure was shorter among four patients who had three DAMA applications (mean, 8.3 weeks; range, 4.0-11.0 weeks) than among three patients who had only one application (mean, 12.1 weeks; range, 9.5-13.5 weeks). CONCLUSIONS: Chronic, unresolved DFUs treated with DAMA rapidly improved and reached closure in an average of 9.2 weeks. These cases suggest that DAMA can facilitate closure of DFUs that have failed to respond to standard treatments.

Growth factors in wound healing: the present and the future?

Numerous clinical studies have confirmed the pivotal role growth factors play in wound healing and their diminished levels in the chronic wound. Despite promising early studies treating chronic wounds with growth factors, results with traditional bolus dosing of a single growth factor have yielded insignificant results. Disappointing results have been theorized to be the result of growth factors inherent short half-life, a hostile microenvironment rich in protease activity, and poor delivery mechanisms failing to deliver effective dosages in an appropriate temporal manner. Advances in tissue engineering and regenerative medicine have provided technologies capable of delivering multiple growth factors in a spatially oriented approach. These technologies include polymer systems, scaffolds, and hydrogels that have demonstrated improved response by target tissues when growth factors are delivered in this biomimetic fashion. With improved delivery systems, treatment of chronic wounds with growth factors has the potential to accelerate healing in a manner not previously realized with traditional delivery approaches.

Offloading of the diabetic foot: orthotic and pedorthic strategies.

The diabetic foot is more susceptible than the non-diabetic foot to collapse. This frequently leads to bony prominences followed by ulceration. Offloading of areas of increased pressure is paramount to ulcer prevention and healing. Several devices and accommodations can aid practitioners in saving patients' extremities and allow them to ambulate. A team approach works best, and patient education is a must. Regular assessment and modifications are required for longevity of each device. In this article, different therapeutic options are detailed. A variety of presentations and situations are discussed and the authors' best tips for avoiding complications are offered.

Validation of the American College of Foot and Ankle Surgeons Scoring Scales.

The American College of Foot and Ankle Surgeons (ACFAS) assembled a task force to develop a scoring scale that could be used by the membership and practitioners-at-large. The original publication that introduced the scale focused primarily on use of the scale and provided only brief background on the development of the health measurement instrument. Concerns regarding the validity and reliability of the scale were raised within the professional community, and ACFAS assembled a task force to address these concerns. The purpose of this article is to address the issues raised by reporting the detailed methods used in the development of the ACFAS Scoring Scales. The authors who constitute this task force reviewed the body of work previously conducted and applied standards that serve to evaluate the scoring scale for: 1) validity, 2) reliability, and 3) sensitivity to change. The results showed that a systematic and comprehensive approach was used in the development of the scoring scales, and the task force concluded that the statistical methods and instrument development process for all 4 modules of the scoring scales were conducted in an appropriate manner. Furthermore, modules 1 and 2 have been rigorously assessed and the elements of these modules have been shown to meet standards for validity, reliability, and sensitivity to change.

Foot muscle energy reserves in diabetic patients without and with clinical peripheral neuropathy.

OBJECTIVE To investigate changes in the foot muscle energy reserves in diabetic non-neuropathic and neuropathic patients. RESEARCH DESIGN AND METHODS We measured the phosphocreatinine (PCr)/inorganic phosphate (Pi) ratio, total (31)P concentration, and the lipid/water ratio in the muscles in the metatarsal head region using MRI spectroscopy in healthy control subjects and non-neuropathic and neuropathic diabetic patients. RESULTS The PCr/Pi ratio was higher in the control subjects (3.23 +/- 0.43) followed by the non-neuropathic group (2.61 +/- 0.36), whereas it was lowest in the neuropathic group (0.60 +/- 1.02) (P < 0.0001). There were no differences in total (31)P concentration and lipid/water ratio between the control and non-neuropathic groups, but both measurements were different in the neuropathic group (P < 0.0001). CONCLUSIONS Resting foot muscle energy reserves are affected before the development of peripheral diabetic neuropathy and are associated with the endothelial dysfunction and inflammation.

The Charcot foot: a clinical challenge.

The Charcot foot (CF) is a clinical challenge. The CF occurs in the presence of sensory neuropathy; its etiology and pathogenesis are constantly debated. The aim of this short article is to examine therapeutic options from the perspective of experienced podiatrists.

Elective surgery of the diabetic foot.

It has been clearly demonstrated that elective surgery can be performed in the neuropathic foot. If infection is controlled and arterial supply is adequate, limb salvage can be greatly enhanced with an aggressive approach to elective procedures in the patient who has diabetes.