Evidence based review of literature on detriments to healing of diabetic foot ulcers.

BACKGROUND: Diabetes mellitus places a substantial burden on society worldwide. Diabetic foot ulcers are a challenging problem for clinicians. Seven generally accepted detriments to healing of diabetic foot ulcers were identified: infection, glycaemic control, vascular supply, smoking, nutrition, deformity and offloading. The aim of this paper is to present a comprehensive evidence based review of the literature available on detriments to healing of diabetic foot ulcers. METHOD: A research question was generated for each of the detriments to healing and a comprehensive review of the literature was performed using the Pubmed database in July 2014. All articles were assessed for relevancy and a level of evidence was assigned. An analysis of the total body of literature was used to assign a grade of recommendation to each detriment. RESULTS: Grade A recommendation was assigned to offloading as there was good evidence supporting this intervention. Grade B recommendation was assigned to deformity as there was fair evidence consistent with the hypothesis. Infection and vascular supply had poor quality evidence supporting the research question and grade C recommendation was assigned. Grade I recommendation was assigned to glycaemic control, smoking and nutrition as there was insufficient and conflicting evidence available. CONCLUSION: Our literature review revealed good evidence for some factors and insufficient literature on others. Further studies are needed to provide quality evidence regarding detriments to healing of diabetic ulcers.

A Prospective Study of Four Total Ankle Arthroplasty Implants by Non-Designer Investigators.

BACKGROUND: There are several types of prostheses available to surgeons when performing a total ankle arthroplasty (TAA). The main objective of this study was to summarize the clinical and functional outcomes of 4 TAA prostheses: the Hintegra implant (Integra LifeSciences), the Agility implant (DePuy), the Mobility implant (DePuy), and the Scandinavian Total Ankle Replacement (STAR) implant (Small Bone Innovations [SBi]). METHODS: Patients were prospectively recruited. A total of 451 TAAs with a mean follow-up (and standard deviation) of 4.5 ± 2.0 years were included. Patients were assessed annually and completed self-reported outcome measures at these visits. Complications and revisions were reported at the time of incident. Mean improvements are reported by prosthesis. Linear mixed-effects models were used to obtain adjusted comparisons of scores across prostheses. Survivorship curves were generated by prosthesis and type of complication. RESULTS: Mean improvement in the Ankle Osteoarthritis Scale (AOS) total score was less among patients with the Mobility implant (19.5; 95% confidence interval [CI], 15 to 24) than it was among patients with the Agility implant (29.1; 95% CI, 24 to 34), Hintegra implant (29.7; 95% CI, 27 to 33), and STAR implant (28.5; 95% CI, 23 to 34). Patients in the Mobility group also had less mean improvement in the AOS pain score (21.3; 95% CI, 17 to 26) compared with patients in the Hintegra (29.0; 95% CI, 26 to 32), Agility (29.8; 95% CI, 25 to 35), and STAR (29.1; 95% CI, 23 to 35) groups. The Mobility group also had less mean improvement in the AOS disability score (17.3; 95% CI, 12 to 23) compared with the Hintegra (30.4; 95% CI, 27 to 34), Agility (28.8; 95% CI, 23 to 34), and STAR (27.8; 95% CI, 21 to 34) groups. Survival results among the 4 prostheses are reported. CONCLUSIONS: This study demonstrated acceptable outcomes of 4 modern TAA prostheses. Outcome results from patient-reported scores were comparable between at least 3 of the 4 prostheses (the Hintegra, STAR, and Agility implants). The rates of complications and revisions found in this study are within the limits reported in the literature for similar prostheses and methods of reporting. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.