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.

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.

A deeper look at low-frequency contact ultrasonic debridement in the clinical management of patients with diabetic foot ulcers.

The current study aimed to evaluate the dispersal of solution and microbes (aerosol) in the clinical environment during treatment with Low-frequency contact ultrasonic debridement (LFCUD) with or without suction attachment in patients with diabetic foot ulcers (DFUs). We performed 20 treatments in 10 patients divided into two groups to receive the proposed LFCUD modalities. We measured the microbial load of the environment pre-treatment (sample M1), during treatment with each LFCUD modality (sample M2) and post-treatment (sample M3). The use of LFCUD debridement without a suction attachment results in significantly higher immediate contamination of the clinic environment than the suction attachment, particularly during the procedure (1.70 ± 0.98 log 10 CFU/mL versus 0.77 ± 0.85 log 10 CFU/mL, p = 0.035). When suction is not applied, there are statistically significant differences depending on whether the DFUs are neuropathic or neuroischemic, finding a greater number of microorganisms with high loads in neuropathic DFUs. We found a statistically significant positive correlation between wound area (r = 0.450, p = 0.047) and TBI (r = 0.651, p = 0.006) with the bacterial load during the LFCUD. Based on our results, we recommend using the personal protective equipment required to protect staff members and patients during treatment with LFCUD and using a suction attachment where clinically possible to reduce clinic environmental pollution, especially in neuropathic DFUs and those with larger areas.

Intra-Observer and Inter-Observer Reliability of Ankle Circumference Measurement in Patients with Diabetic Foot: A Prospective Observational Study.

Inflammation, being a typical response to vascular tissue alterations, induces variations in tissue oxygen diffusion pressure. Diabetic microangiopathy, an inflammatory process, is characterized by an increase in vascular flow at rest, reduced venous and arteriolar responses, and increased capillary permeability, resulting in oedema development, decreased transcutaneous oxygen pressure, and increased transcutaneous carbon dioxide pressure. This phenomenon potentially hampers ulcer healing. Although the figure-of-eight method has proven to be a reliable, valid, quick, and efficient test for assessing foot and ankle measurements in patients with oedema and compromised skin integrity, it has not been studied in patients with diabetic foot. The aim of this study was to determine and compare the intra- and inter-observer variabilities of the figure-of-eight method in patients with diabetic foot. A prospective observational and cross-sectional study was undertaken, involving sixty-one subjects from a specialized Diabetic Foot Unit. Three investigators with varying levels of experience independently measured the subjects to assess both intra-observer and inter-observer variability. The evaluation was conducted using the Intraclass Correlation Coefficient (ICC). In the statistical analysis, an ICC of 0.93, adjusted using a 95% confidence interval (CI), was obtained for inter-observer reliability ICC, indicating excellent reliability among observers. Furthermore, an ICC of 0.98 with a 95% CI was obtained for the intra-observer reliability analysis, indicating excellent reliability. The results support using this test during the clinical management of oedema in patients with diabetic foot. The absence of an objective, fast, and readily available diagnostic method for oedema in diabetic foot patients in clinical practice might pose a limitation. Subsequent research should tackle this issue and explore the correlation between ankle perimeter measurements and other clinical outcomes in diabetic foot patients, including wound healing and quality of life.

Cryotherapy versus topical nitric-zinc complex solution for the treatment of plantar warts: A randomized controlled trial.

Cryotherapy is commonly regarded as the primary treatment method for plantar warts. A new medical device called nitric-zinc complex solution (NZCS) has also emerged as a potential alternative for wart treatment. The main aim of this study was to analyze and compare the effectiveness of cryotherapy using liquid nitrogen and NZCS in treating plantar warts. We conducted a randomized and controlled clinical trial involving patients with plantar warts. A total of 62 patients were enrolled in the study and monitored for 12 weeks or until their warts were completely resolved. The patients received either cryotherapy or NZCS, with a maximum of six treatment applications. The cure rate was 65.5% in the group treated with cryotherapy and 56.6% in the group treated with NZCS. The average number of treatment applications required for curing warts was significantly lower in the cured group (3.28 ± 1.63) than in the group with unresolved warts (5.5 ± 1.27) (p < 0.01). Moreover, the average number of applications was lower in the cryotherapy group (3.6 ± 1.8) than in the NZCS group (4.8 ± 1.8) (p < 0.01). Based on the findings, NZCS could be considered a favorable first-line treatment option for plantar warts.

Comparative Analysis of Bone Resection Versus Bone Curettage in Diabetic Foot Osteomyelitis.

This study aims to describe the healing times of patients who underwent bone resection compared to bone curettage for managing diabetic foot osteomyelitis and to compare short- and long-term complications. This analytical retrospective observational cohort study collected clinical records of patients from a specialized diabetic foot clinic who underwent resection or bone curettage between January 2017 and January 2022. After surgery, a 1-year follow-up was conducted to record healing times and short- and long-term complications. The study included thirty-one patients, with 19 (61.29%) undergoing resections and 11 (38.71%) undergoing bone curettages. The resection cohort had a mean healing time of 5.70 ± 6.05 weeks, whereas the curettage cohort had a mean healing time of 14.45 ± 11.78 weeks, showing a statistically significant difference (P = 0.011). No significant differences were observed in terms of short- and long-term complications. In the resection cohort, 12 (63.20%) experienced short-term complications, compared to eight (66.70%) in the curettage cohort (P = 0.842, χ2 = 0.40, OR = 1.16). In the resection cohort, n = 6 (31.60%) had long-term complications, while n = 3 (25.00%) in the curettage cohort experienced long-term complications (P = 0.694, χ2 = 0.155, OR = 0.72). Although there were no significant differences in short- and long-term complications between resection and curettage, the resection group showed shorter healing times.

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.

Analysis of the Influence of Diabetic Nephropathy in Patients with Diabetic Foot Osteomyelitis.

This study analyzed the influence of diabetic nephropathy on the healing prognosis after conservative surgery in diabetic foot osteomyelitis (DFO). A retrospective observational study was carried out between January 2021 and December 2022 and involved 278 outpatients with a diagnosis of DFO at a specialized diabetic foot unit, including 74 (26.62%) patients with DN (group 2) and 204 (73.38%) patients without DN (group 1). There were 266 (95.70%) ulcers on the forefoot, 8 (2.90%) on the midfoot, and 4 (1.45%) on the hindfoot (p = 0.992). The healing rates were 85.1% (n = 63) for group 2 and 81.3% (n = 165) for group 1 (p = 0.457). When exploring the influence of DN on the risk of delayed ulcer healing, the results did not show a significant effect [12 (6; 28) weeks among patients with DN vs. 12 (6; 21) weeks among patients without DN; p = 0.576]. No significant differences were observed in complications, with one (2.59%) death occurring in group 1 (p = 0.296) and three minor amputations being performed in both groups [two (5.13%) amputations in group 1 vs. one amputation (9.09%) in group 2; p = 0.217]. Bone cultures were performed for a total of 190 patients (133 in group 1 and 57 in group 2). Of these, 176 positive bone cultures were isolated: 71 positive bone cultures (57.7%) were monomicrobial cultures in group 1, with 30 (56.6%) in group 2. There were 52 (42.3%) that had at least two microorganisms in group 1, and 23 (43.4%) in group 2 (p = 0.890). The most frequently prescribed oral antibiotic was amoxicillin/clavulanate (43.89%), followed by levofloxacin (28.4%), and trimethoprim/sulfamethoxazole (14.7%). This study shows that DN does not have a significant influence on the healing prognosis of patients with DFO after conservative surgery.

Is the Combination of Plain X-ray and Probe-to-Bone Test Useful for Diagnosing Diabetic Foot Osteomyelitis? A Systematic Review and Meta-Analysis.

A systematic review and meta-analysis was conducted to assess the diagnostic accuracy of the combination of plain X-ray and probe-to-bone (PTB) test for diagnosing diabetic foot osteomyelitis (DFO). This systematic review has been registered in PROSPERO (a prospective international register of systematic reviews; identification code CRD42023436757). A literature search was conducted for each test separately along with a third search for their combination. A total of 18 articles were found and divided into three groups for separate analysis and comparison. All selected studies were evaluated using STROBE guidelines to assess the quality of reporting for observational studies. Meta-DiSc software was used to analyze the collected data. Concerning the diagnostic accuracy variables for each case, the pooled sensitivity (SEN) was higher for the combination of PTB and plain X-ray [0.94 (PTB + X-ray) vs. 0.91 (PTB) vs. 0.76 (X-ray)], as was the diagnostic odds ratio (DOR) (82.212 (PTB + X-ray) vs. 57.444 (PTB) vs. 4.897 (X-ray)). The specificity (SPE) and positive likelihood ratio (LR+) were equally satisfactory for the diagnostic combination but somewhat lower than for PTB alone (SPE: 0.83 (PTB + X-ray) vs. 0.86 (PTB) vs. 0.76 (X-ray); LR+: 5.684 (PTB + X-ray) vs. 6.344 (PTB) vs. 1.969 (X-ray)). The combination of PTB and plain X-ray showed high diagnostic accuracy comparable to that of MRI and histopathology diagnosis (the gold standard), so it could be considered useful for the diagnosis of DFO. In addition, this diagnostic combination is accessible and inexpensive but requires training and experience to correctly interpret the results. Therefore, recommendations for this technique should be included in the context of specialized units with a high prevalence of DFO.

Effectiveness of Percutaneous Flexor Tenotomies for the Prevention and Management of Toe-Related Diabetic Foot Ulcers: A Systematic Review.

There is a high prevalence of digital deformities in diabetic patients, particularly claw toe, which can result in ulceration, often located at the tip of the toe. These lesions are challenging to off-load with conventional devices and frequently lead to infection and high amputation rates. Recent guidelines recommend considering flexor tenotomies to manage these ulcerations and prevent complications. This review, which analyzed 11 studies, aimed to assess the effect of flexor tenotomies on the healing and prevention of diabetic foot ulcers (DFUs) at the toe tip. Satisfactory results were found, with a healing rate of 92% to 100% and a mean healing time of 2-4 weeks. Few mild complications were observed, and the recurrence rate was very low. Transfer lesions were the most prevalent, but simultaneous tenotomy of all toes can eliminate this risk. Flexor tenotomies are a simple, effective, and safe procedure for the treatment and management of DFUs located at the apex of the toes and should be considered part of the standard of care for diabetic feet.

Bacterial Diversity and Antibiotic Resistance in Patients with Diabetic Foot Osteomyelitis.

This study analysed the bacterial diversity, antibiotic susceptibility, and resistance in patients with complications of diabetic foot osteomyelitis (DFO). A retrospective observational study was carried out between September 2019 and September 2022 and involved 215 outpatients with a diagnosis of DFO at a specialized diabetic foot unit. A total of 204 positive bone cultures were isolated, including 62.7% monomicrobial cultures, and 37.3% were formed with at least two microorganisms. We observed that Proteus spp., Coagulase-negative staphylococci (CoNS), Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and Corynebacterium were the most frequently isolated microorganisms and accounted for more than 10% of the DFO cases. With stratification by Gram-positive (GP) and Gram-negative (GN) bacteria, we observed that 91.6% of cultures presented at least one GP bacteria species, and 50.4% presented at least one GN bacteria species. The most common GP species were CoNS (29%), S. aureus (25.8%), and Corynebacterium spp. (14%). The most frequent GN species consisted of Proteus spp. (32%), P. aeruginosa (23.3%), and E. coli (17.5%). The main antibiotics with resistance to GP-dominated infections were penicillins without ß-lactamase inhibitor, and those in GN-dominated infections were sulfonamides and penicillins without ß-lactamase. Significant differences were not observed in mean healing time in DFU with acute osteomyelitis (12.76 weeks (4.50;18)) compared to chronic osteomyelitis (15.31 weeks (7;18.25); p = 0.101) and when comparing cases with soft tissue infection (15.95 (6;20)) and those without such an infection (16.59 (7.25;19.75), p = 0.618). This study shows that when treatment of DFO is based on early surgical treatment, the type of DFO and the presence of soft infection are not associated with different or worse prognoses.

Microcirculation Improvement in Diabetic Foot Patients after Treatment with Sucrose Octasulfate-Impregnated Dressings.

To assess the patients' microcirculation evolution during the treatment with a sucrose octasulfate-impregnated dressing, fifty patients with neuroischaemic DFU treated with TLC-NOSF dressing were included in a prospective study between November 2020 and February 2022. TcpO2 values were measured on the dorsalis pedis or tibial posterior arteries' angiosome according to the ulcer location. TcpO2 values were assessed at day 0 and every 4 weeks during 20 weeks of the follow-up or until the wound healed. A cut-off point of tcpO2 < 30 mmHg was defined for patients with impaired microcirculation. The TcpO2 values showed an increase between day 0 and the end of the study, 33.04 ± 12.27 mmHg and 40.89 ± 13.06 mmHg, respectively, p < 0.001. Patients with impaired microcirculation showed an increase in the tcpO2 values from day 0 to the end of the study (p = 0.023). Furthermore, we observed a significant increase in the TcpO2 values in the forefoot DFU (p = 0.002) and in the rearfoot DFU (p = 0.071), with no difference between the ulcer locations (p = 0.694). The local treatment with TLC-NOSF dressing improved the microcirculation in patients with neuroischaemic DFU, regardless of microcirculation status at the baseline, and in the forefoot, regardless of the location.

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.

The Influence of Arterial Calcification on Clinical Outcomes in Patients with Diabetic Foot Ulcer Complicated by Osteomyelitis Treated by Surgery.

The aim of our study was to analyze the influence of radiographic arterial calcification (RAC) on clinical outcomes and wound healing in patients with diabetic foot ulcers complicated by osteomyelitis treated by surgery. We analyzed retrospectively the clinical records of 102 patients with diabetic foot osteomyelitis who underwent surgery at a specialized diabetic foot unit between January 2014 and December 2016. The clinical data of evolution until its complete epithelialization and a follow-up 1 year were reviewed, and after reviewing the radiological images, patients were classified into 2 groups: those with RAC and those without RAC. We analyzed several clinical features in both groups. The presence of RAC was associated with a greater time of healing (10.68 ± 7.24 vs 8.11 ± 4.50 weeks; P = .029) and shorter time to recurrence and reulceration (13.30 ± 9.25 vs 18.81 ± 11.63 weeks; P = .036). However, this association was not found for patients with mild and moderate peripheral artery disease (PAD), whose time of healing was 8.97 ± 4.51 weeks compared to 9.16 ± 6.39 weeks for patients without PAD; P = .864. The time of healing of diabetic foot ulcers complicated by osteomyelitis treated by surgery can be negatively affected by the presence of RAC even more than by the presence of mild and moderate ischemia. The presence of RAC may offer clinical guidance at the level of primary care though this would need thorough validation in future studies.

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.

Predictive value of forefoot plantar pressure to predict reulceration in patients at high risk.

AIMS: To analyze a plantar pressure cut-off point for diabetic foot reulceration beneath the metatarsal heads in patients with previous forefoot amputation. METHODS: A one-year prospective study was conducted in a total of 105 patients at high risk for foot ulceration. Peak plantar pressure (PPP) and pressure-time integral (PTI) in the entire foot, the forefoot region, and each metatarsal head separately were registered. ROC curves were used to select the optimal diagnostic pressure cut-off points. Patients were follow-up monthly or until the development of an ulcer event. RESULTS: A total of 52 (49.5%) patients developed a reulceration. Using ROC analyses for PPP in the full-foot and in the forefoot, did not predict reulceration beneath the metatarsal heads. Analyzing separately each metatarsal head all patients with values greater than or equal to 20.8 N/cm2 at the 1st, 18.62 N/cm2 for the 2nd, 18.85 at the 3rd, 17.88 at the 4th, and 12.2 at the 5th metatarsal heads will suffer a reulceration despite the use of orthopedic treatment with optimum values of sensitivity (from 100 to 87.5) and specificity (from 83.2 to 62.8). CONCLUSION: Barefoot pressures beneath the metatarsal heads should be analyzed separately to predict the region at risk of reulceration.

Clinical and Histological Outcomes of Negatively Charged Polystyrene Microspheres Applied Daily Versus Three Times per Week in Hard-to-Heal Diabetic Foot Ulcers: A Randomized Blinded Controlled Trial.

Negatively charged polystyrene microspheres (NCMs) have been demonstrated as a novel and effective therapy for managing hard-to-heal diabetic foot ulcers (DFUs). However, one limitation of this therapy is that the protocol is based on daily application, which sometimes does not fit local protocols of wound care. Thus, we aimed to analyze the safety and efficacy of a new dose regimen. We conducted a randomized blinded controlled trial in a specialized diabetic foot unit between May 2019 and February 2021 with a total of 30 patients who had neuropathic or neuroischemic DFUs that had not responded after four weeks of standard treatment. Patients were randomized consecutively into a group that received daily application (control) or one that received applications three times per week (experimental). The clinical outcomes were evaluated using the Wollina score and wound-area reduction (WAR) weekly during a treatment period of 28 days. The histological outcomes were assessed using a soft-tissue punch biopsy (3 mm) at 0, 14, and 28 days to evaluate cellular proliferation. The Wollina scores were higher at the end of treatment by week 4 in both groups, but the differences were not significant between groups. The averages were 6 (5, 7) points in Experimental group (EG) and 6 (6,7) points in Control group (CG) (p = 0.848). Wound area reduction at day 28 was 53.57 [37.43, 79.16] % in the CG and 79.37 [42.74, 93.57] % in the EG, without differences among groups (p = 0.305). Cellular proliferation was similar in both groups at day 28. Application three times per week showed similar clinical and histological outcomes to those of daily application, both dose regimens demonstrated significant improvement of granulation tissue formation and WAR during the treatment.

Ultrasound-Assisted Wound (UAW) Debridement in the Treatment of Diabetic Foot Ulcer: A Systematic Review and Meta-Analysis.

A systematic review and meta-analysis were carried out to investigate the effect of ultrasound-assisted wound (UAW) debridement in patients with diabetic foot ulcers (DFUs). All selected studies were evaluated using the Cochrane risk of bias tool to assess the risk of bias for randomized controlled trials. PubMed and Web of Science were searched in October 2021 to find randomized clinical trials (RCT) assessing the effect of UAW debridement on DFUs. RevMan v5.4. was used to analyze the data with the Mantel-Haenszel method for dichotomous outcomes. A total of 8 RCT met our inclusion criteria, with 263 participants. Concerning the healing rate comparing UAW versus the control group, a meta-analysis estimated the pooled OR at 2.22 (95% CI 0.96-5.11, p = 0.06), favoring UAW debridement, with low heterogeneity (x2 = 7.47, df = 5, p = 0.19, I2 = 33%). Time to healing was similar in both groups: UAW group (14.25 ± 10.10 weeks) versus the control group (13.38 ± 1.99 weeks, p = 0.87). Wound area reduction was greater in the UAW debridement group (74.58% ± 19.21%) than in the control group (56.86% ± 25.09%), although no significant differences were observed between them (p = 0.24). UAW debridement showed higher healing rates, a greater percentage of wound area reduction, and similar healing times when compared with placebo (sham device) and standard of care in patients with DFUs, although no statistically significant differences were observed between groups.