Acute effect of hyperbaric oxygen therapy on macular and choroidal thickness in patients with type 2 diabetes and diabetic foot ulcers: Optical coherence tomography based study.

PURPOSE: To evaluate the acute effect of hyperbaric oxygen therapy (HBOT) on central macular thickness (CMT) and choroidal thickness (CT) in patients with type 2 diabetes mellitus (T2D) undergoing HBOT due to diabetic foot ulcer (DFU). METHODS: For this cross-sectional study, patients with T2D were recruited between May 2019 and June 2020. Only eyes with non-proliferative or no diabetic retinopathy (DR) were included. CMT and subfoveal, nasal, and temporal CT values measured by spectral-domain optical coherence tomography (Nidek RS-3000 Advance, Aichi, Japan) before and 45 minutes after the first HBOT session were compared between eyes with and without DR and between patients receiving only insulin therapy (group 1) or insulin+oral antidiabetic (group 2). Relationships between post-HBOT change in these parameters and age, sex, HbA1c level, and DR presence and stage were evaluated. RESULTS: The study included 49 eyes of 26 patients with DFU (aged 43-75 years). Post-HBOT changes in CMT and CT were not significant or associated with age, gender, DR stage, or HbA1c level (p > 0.05). Eyes with DR had significantly higher pre- and post-HBOT CMT, nasal CT, and temporal CT values compared to non-DR eyes. Nasal CT increased significantly after HBOT in eyes with DR. Group 1 (28 eyes, 15 patients) had higher pre-HBOT mean subfoveal CT and greater post-HBOT change in subfoveal CT than group 2 (21 eyes, 11 patients). CONCLUSIONS: HBOT was not associated with acute changes in CMT or CT in patients with T2D, although an increase in nasal CT was observed in eyes with DR.

Single stage treatment of diabetic calcaneal osteomyelitis with an absorbable gentamicin-loaded calcium sulphate/hydroxyapatite biocomposite: The Silo technique.

BACKGROUND: Chronic osteomyelitis necessities appropriate infected bone and soft tissue excision. The authors describe the Silo surgical technique for the treatment of calcaneal osteomyelitis using a new antibiotic-loaded absorbable calcium sulphate/hydroxyapatite biocomposite. METHODS: The Silo method involves debridement of the dead bone and local delivery of antibiotic in drilled tunnels using the biocomposite. It is combined with multiple sampling and culture-specific systemic antibiotic treatment guided by a multidisciplinary team. Twelve consecutive diabetic patients with heel ulcers and calcaneal osteomyelitis were treated with the above method. All had comorbidities (Cierny-Mader (C-M) Class B hosts). The mean age was 68 years (range 50-85). A retrospective review of radiographs and electronic medical records was conducted. RESULTS: Patients were followed up until clinical cure of the ulcer for a mean of 16 weeks (range 12-18). Infection was eradicated in all 12 patients with a single stage procedure following a bone preserving technique. One patient required a subsequent flap operation and six vacuum-assisted closure (V.A.C.). There was also one case of prolonged wound leakage and no calcaneal fractures. CONCLUSIONS: The Silo technique is an effective method of local delivery of antibiotics and can be effectively implemented into the single-stage treatment of calcaneal osteomyelitis offering increased bone preservation and local delivery of antibiotic, decreasing the need for a major amputation. LEVEL OF EVIDENCE: Level IV- case series.

Preliminary Evaluation of a Cycling Cleat Designed for Diabetic Foot Ulcers.

BACKGROUND: Offloading devices for diabetic foot ulcers (DFU) generally restrict exercise. In addition to traditional health benefits, exercise could benefit DFU by increasing blood flow and acting as thermotherapy. This study functionally evaluated a cycling cleat designed for forefoot DFU. METHODS: Fifteen individuals at risk of developing a DFU used a recumbent stationary bicycle to complete one 5-minute cycling bout with the DFU cleat on their study foot and one 5-minute bout without it. Foot stress was evaluated by plantar pressure insoles during cycling. Laser Doppler perfusion monitored blood flow to the hallux. Infrared photographs measured foot temperature before and after each cycling bout. RESULTS: The specialized cleat significantly reduced forefoot plantar pressure (9.9 kPa versus 62.6 kPa, P < .05) and pressure time integral (15.4 versus 76.4 kPa*sec, P < .05). Irrespective of footwear condition, perfusion to the hallux increased (3.97 ± 1.2 versus 6.9 ± 1.4 tissue perfusion units, P < .05) after exercise. Infrared images revealed no changes in foot temperature. CONCLUSIONS: The specialized cleat allowed participants to exercise with minimal forefoot stress. The observed increase in perfusion suggests that healing might improve if patients with active DFU were to use the cleat. Potential thermotherapy for DFU was not supported by this study. Evaluation of the device among individuals with active DFU is now warranted.

MRI assessment of regional differences in phosphorus-31 metabolism and morphological abnormalities of the foot muscles in diabetes.

PURPOSE: To assess differences in the phosphorus-31 (31 P) metabolism and morphology in multiple muscle regions in the forefoot of diabetic patients and normal subjects. MATERIALS AND METHODS: Fifteen diabetic patients and 15 normal subjects were assessed for muscle atrophy by 1 H magnetic resonance imaging (MRI) at 3T to grade the flexor hallucis, adductor hallucis, interosseous regions, and entire foot cross-section. Each region and the entire foot were also quantitatively evaluated for metabolic function using 31 P imaging for spatial mapping of the inorganic phosphate (Pi) to phosphocreatine (PCr) ratio (Pi/PCr). The ratio of viable muscle area to the predefined region areas (31 P/1 H) was calculated. The variability of each method was assessed by its coefficient of variation (CV). RESULTS: Muscle atrophy was significantly more severe in diabetic compared to normal subjects in all regions (P < 0.01). The 31 P/1 H area ratio was significantly larger in the adductor hallucis than in the other two regions (P < 0.05). The Pi/PCr ratio was significantly different between the two groups in the flexor hallucis and interosseous regions (P < 0.05) but not adductor hallucis region. The CV for Pi/PCr ranged from 10.13 to 55.84, while it ranged from 73.40 to 263.90 for qualitative grading. CONCLUSION: Changes in atrophy and metabolism appear to occur unequally between different regions of the forefoot in diabetes. The adductor hallucis region appears more capable of maintaining structural and metabolic integrity than the flexor hallucis or interosseous regions. The CV analysis suggests that the quantitative 31 P methods have less variability than the qualitative grading. J. Magn. Reson. Imaging 2016;44:1132-1142.

Ostectomy and Medial Plantar Artery Flap Reconstruction for Charcot Foot Ulceration Involving the Midfoot.

Charcot foot is a serious complication of diabetes, characterized by deformity and overlying ulceration. The condition most commonly affects the midfoot. However, little information is available on the use of a medial plantar artery flap to treat diabetic midfoot ulceration. The purpose of the present study was to evaluate the versatility of ostectomy and medial plantar flap reconstruction for midfoot plantar ulceration associated with rocker-bottom deformity secondary to Charcot foot. Four patients underwent ostectomy and medial plantar flap reconstruction. Before flap reconstruction, the devitalized soft tissues and bone were radically resected. After the infection had been controlled, the ulcerated portion was minimally excised, and the bony prominence underlying the ulcer was removed. A medial plantar artery flap was applied to the ulcer. The donor site was covered with a split-thickness skin graft or artificial dermis. In all patients, the ulcers healed and independent ambulation was achieved. However, 1 patient experienced ulcer recurrence, and subsequent infection necessitated a major amputation. Limb salvage is challenging in the setting of deformity and intractable plantar ulceration. The advantages of medial plantar artery flap reconstruction are that tissues with a rich blood supply are used to cover the exposed bone, and the flap can withstand the pressure and shear stress of the patient's body weight. However, a dominant artery in the foot is sacrificed. Therefore, the patency of the dorsalis pedis artery must be confirmed in every patient. The results of the present study have demonstrated that a medial plantar artery can be an effective alternative for diabetic patients with a plantar ulcer secondary to Charcot foot.

Diabetic foot ulcers: Part II. Management.

The management of diabetic foot ulcers can be optimized by using an interdisciplinary team approach addressing the correctable risk factors (ie, poor vascular supply, infection control and treatment, and plantar pressure redistribution) along with optimizing local wound care. Dermatologists can initiate diabetic foot care. The first step is recognizing that a loss of skin integrity (ie, a callus, blister, or ulcer) considerably increases the risk of preventable amputations. A holistic approach to wound assessment is required. Early detection and effective management of these ulcers can reduce complications, including preventable amputations and possible mortality.

A study of HVPC as an adjunctive therapy in limb salvage for chronic diabetic wounds of the lower extremity.

Complex diabetic ulcers of the lower extremity can be slow to heal and may lead to amputation. A retrospective study was conducted to evaluate the effect of a form of electrical stimulation using high-voltage, pulsed current (HVPC) as an adjunct to a multidisciplinary approach to limb salvage for chronic diabetic wounds of the lower extremity. Data from 30 patients with diabetes (17 men, 13 women, mean age 65.8 +/- 12.6 years, mean HgbA1c level = 8.2 +/- 1.5, with varying comorbidities) and 45 wounds were reviewed. Mean wound duration before referral and treatment was 25.0 weeks (range 4.0 to 60.0) and the mean wound surface area was 7.8 cm2 (range 0.6 cm2 to 62.0 cm2). The majority (62.2%) of wounds were classified 1C, 2C, or 3D (University of Texas diabetic wound classifications). The mean number of treatments, administered two or three times a week, was 23.0 (range 6.0 to 65.0) and 35 wounds (77.8%) healed after a mean of 14.2 weeks (range 3.4 to 59.0). Of those, 31 remained healed at a mean follow-up of 39.8 weeks (range 11.1 to 84.3) and additional HVPC healed two of the four recurrences. These results suggest that HVPC is a useful addition to a multidisciplinary limb salvage management approach for complex lower extremity wounds. Further study is warranted to elucidate its role in this application.

Efficacy of indigenously developed single vial kit preparation of 99mTc-ciprofloxacin in the detection of bacterial infection: an Indian experience.

OBJECTIVE: To investigate the diagnostic efficacy of indigenously developed single vial kit preparation of Tc-ciprofloxacin (Diagnobact) for the detection of orthopedic infections. METHODS: Seventy-seven patients [25 with clinical suspicion of diabetic foot osteomyelitis (DFOM), 25 with orthopedic device-related infection (ODRI) and 27 with tubercular bone infection] underwent three-phase Tc-methylenediphosphonate bone scintigraphy followed by static Tc-ciprofloxacin imaging at 1, 4 and 24 h. Imaging (anterior and posterior views) was performed under a dual-head gamma-camera using a low-energy, high-resolution, parallel-hole collimator. The lesion-to-background ratio (LBR) of the radiotracer was calculated on the static isotime Tc-ciprofloxacin images using semiquantitative analysis. Scintigraphic (Diagnobact) results were compared with the histopathological and/or culture/PCR analysis as a gold standard. RESULTS: The mean LBR of the radiotracer (Tc-ciprofloxacin) in the positive scans (n=29; 16 ODRI, 13 DFOM) was > or =2.0 at 1 h postinjection and remained consistent till 24 h. In contrast, the mean LBR in the negative scans (n=21; 12 DFOM, nine ODRI) was < or =1.5 at 1 h and declined significantly (P<0.05) at 24 h. The observed trend in the mean LBR in positive (n=18) and negative (n=9) scans for tubercular osteomyelitis was identical to that seen in the nontubercular bacterial infections. CONCLUSION: The management protocol for patients with suspected bony infection may include a three-phase bone scan followed by Tc-ciprofloxacin scan. An LBR of > or =2.0 at 1 h that remained consistent till 24 h on Tc-ciprofloxacin scan is indicative of active bacterial infection. However, resistance to ciprofloxacin at the bacterial cell membrane may be a limitation of this technique.

Neuropathic osteoarthropathy in the diabetic foot.

OBJECTIVE: To discuss a case involving a 55-year-old diabetic woman with neuropathic osteoarthropathy initiated by a fall. CLINICAL FEATURES: The patient fell into a hole, injuring her left foot. Because of the anesthesia associated with her diabetic peripheral neuropathy, she did not notice the ensuing plantar puncture wound. The patient assumed that her swelling was a result of a sprain. Mild dislocation and osseous fragmentation was noted within the midfoot on radiographs. The neuropathic osteoarthropathy progressed until the patient was later casted. Plain films taken at the time of cast removal demonstrated resorption and consolidation of fragmentation, but the dislocation was unaltered. INTERVENTION AND OUTCOME: The patient was scheduled for surgery and wound debridement. However, before surgery, complications of a burn sustained on the contralateral foot required fifth ray amputation. Surgery of the left foot has been postponed until adequate postsurgical healing has occurred at the right foot amputation site. CONCLUSION: This article provides tools for the timely diagnosis and treatment of neuropathic osteoarthropathy. An increased understanding of this entity will help lead to a reduction in the incidence of delayed treatment resulting from misdiagnosis.

[Staging-syndrome differentiation in treating diabetic foot disorder and its effect on hemodynamic changes of lower extremities with arterial ultrasonic Doppler diagnostic apparatus].

OBJECTIVE: To observe the therapeutic effect of staging-Syndrome Differentiation of TCM in treating the diabetic foot disorder and the corresponding hemodynamic changes in lower extremities. METHODS: Chromatic ultrasonic Doppler diagnostic apparatus (ATL-ULTRAMARK 9 HDI, made in USA) was used to determine the arterial hemodynamic changes and clinical effect on the treatment of diabetic foot disorder in 60 non-insulin dependent diabetes mellitus (NIDDM) patients, among them 30 were treated by staging-Syndrome Differentiation of TCM, and the other 30 as control group treated with 654-2, and the 30 cases of nondiabetic foot disorder as normal control group in comparison. RESULTS: Compared to the normal control, the intravascular diameter, blood flow of both treated groups reduced, maximal and minimal speed of blood flow, and the mean speed were accelerated. Values in dorsal pedis artery had present the most sensitive one. In the comparison between before and after treatment, both treated groups were hemodynamic improvement in the lower extremities' artery, more obviously the dorsal pedis artery, while the comparison between these two groups showed that TCM staging-Syndrome Differentiation had a superior effect on lower extremities' hemodynamics to that of 654-2 group. The comprehensive assessment revealed that the treated groups was also significant different in comparing to that of normal control group (P < 0.05). CONCLUSION: The comprehensive TCM treatment of staging-Syndrome Differentiation as the main therapeutic component was prominently better than that of 654-2 application in the treatment.