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 [...].

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.

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.

Differences in the Sub-Metatarsal Fat Pad Atrophy Symptoms between Patients with Metatarsal Head Resection and Those without Metatarsal Head Resection: A Cross-Sectional Study.

We aimed to evaluate the differences in the sub-metatarsal skin and fat pad atrophy between patients at a high risk of ulceration with and without previous metatarsal head resection. A cross-sectional study was performed in a diabetic foot unit involving 19 participants with a history of metatarsal head resection (experimental group) and 19 (control group) without a history of metatarsal head resection but with an ulcer in other locations in the metatarsal head. No participants had active ulcerations at study inclusion. Sub-metatarsal skin thickness and fat pad thickness in the first and second metatarsals were evaluated by an ultrasound transducer. The experimental group showed sub-metatarsal fat pad atrophy (3.74 ± 1.18 mm and 2.52 ± 1.04 mm for first and second metatarsal, respectively) compared with the control group (5.44 ± 1.12 mm and 4.73 ± 1.59 mm) (p < 0.001, confidence interval: (CI): 0.943-2.457 and p < 0.001, CI: 1.143-3.270 for first and second metatarsal, respectively); however, sub-metatarsal skin thickness was not different between groups (experimental 2.47 ± 0.47 mm vs. control 2.80 ± 0.58 mm (p = 0.063, CI: -0.019-0.672) and 2.24 ± 0.60 mm vs. 2.62 ± 0.50 mm (p = 0.066, CI: -0.027-0.786) for first and second metatarsal, respectively). Patients with previous metatarsal head resection showed sub-metatarsal fat pad atrophy, which could be associated with the risk of reulceration in the metatarsal head.

Role of inflammatory markers in the healing time of diabetic foot osteomyelitis treated by surgery or antibiotics.

OBJECTIVE: To analyse the predictive role of inflammatory markers in the healing time of diabetic foot osteomyelitis treated by surgery or antibiotics. METHODS: An observational study of patients with diabetic foot ulcers (DFU) and clinically suspected osteomyelitis. The patients underwent surgical or antibiotic treatment for bone infection in a specialised diabetic foot unit. Blood samples were taken from each patient to analyse biomarkers. The main outcome was the number of weeks until healing occurred. RESULTS: A total of 116 patients took part in the study. The number of weeks until healing was similar for both groups (surgical n=96 and antiobiotic n=20, treatments). No association was observed among biomarkers as predictors of time-to-healing. CONCLUSION: There is not enough evidence to define the prognostic role of inflammatory markers in the healing time of DFUs complicated with diabetic foot osteomyelitis, regardless of the treatment administered.

Clinical and Antimicrobial Efficacy of a Silver Foam Dressing With Silicone Adhesive in Diabetic Foot Ulcers With Mild Infection.

The use of an antimicrobial dressing instead of a non-antimicrobial dressing may increase the number of diabetic foot ulcers healed over a medium-term follow-up period. The study aim was to evaluate the clinical and microbiological efficacy of a silver foam dressing in the management of diabetic foot ulcers. We conducted a single-center, prospective, open, noncontrolled study involving 21 outpatients with diabetic foot ulcers with mild infection. All patients received standard of care for their wounds and a silver foam dressing with silicone adhesive was applied twice per week for wound management during a 6-week treatment period. Soft tissue punch biopsies were taken every second week for qualitative and quantitative microbiological analysis. Wounds were assessed at patient admission, and wound bed tissue was evaluated for presence, quality, and consistency of granulation tissue. Clinical evaluation revealed improvements in wound conditions as a result of treatment with the silver dressing. Wollina wound scores improved significantly, from a mean score of 3.9 ± 1.6 points at inclusion to 6.1 ± 1.3 points at the end of the study (n = 19, P < .001). Treatment with the silver dressing resulted in significant decreases in the bioburden of classically considered diabetic foot ulcer pathogenic organisms such as Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus, Enterobacteriaceae species, Pseudomonas aeruginosa, and other nonfermenting gram-negative bacilli. Findings revealed that the use of silver foam dressing significantly reduced the pathogenic bacterial load and markedly improved the clinical outcome in patients with diabetic foot ulcer with mild infection over a 6-week treatment period.

Early Foot Structural Changes After Lateral Column Exostectomy in Patients With Charcot Foot.

Although exostectomy for chronic midfoot plantar ulcers in Charcot foot is apparently effective, with healing rates of nearly 75%, a subset of patients develop recurrent ulceration and show an unstable foot position, especially after undergoing exostectomy confined to the lateral column. The reasons for this failure have not been investigated. The main objective of this study was to evaluate the early changes in radiographic alignment after an exostectomy in patients with Charcot neuropathic osteoarthropathy (rocker bottom) and plantar ulcer located in the lateral column. The present study evaluated retrospectively changes in radiographic alignment after an exostectomy in 12 Charcot feet (rocker bottom) with plantar ulcer located in the lateral column. Indication for plantar exostectomy was the treatment of ulcer affected by osteomyelitis. We evaluated the early changes in the alignment of the foot on weight-bearing lateral radiographs 6 months after exostectomy. Paired sample Wilcoxon test was used to calculate the differences between preoperative and postoperative measurements. Furthermore, the relationship between revision surgery and early changes in radiographic angular measurements was determined by using the Mann-Whitney U test. After exostectomy, the inclination of the calcaneal bone decreased (P = .003; r = 0.849) and declination of talus bone increased (P = .041; r = 0.589). The change in calcaneal inclination was associated with revision surgery (P = .042; r = 0.586). The present case series demonstrates that exostectomy procedure for the lateral column in patients with Charcot foot results in radiological changes in the hindfoot over the sagittal plane. The inversion of the calcaneal pitch angle suggests the possibility of further adverse events and the need for revision surgery.

Metalloproteinases in chronic and acute wounds: A systematic review and meta-analysis.

A systematic review and meta-analysis were undertaken in order to explore the influence of matrix metalloproteinases and their diagnostic methods in chronic and acute wounds. Searches were conducted in the PubMed (Medline) and Embase (Elsevier) databases from inception to late November 2017. We included clinical trials enrolling patients with cutaneous chronic and acute wounds where a validated diagnostic method was employed for metalloproteinases. We excluded in vitro, animal or preclinical studies, nonoriginal articles, and studies without available data for analysis. In addition, references of narrative and systematic reviews were scrutinized for additional articles. Eight studies met the inclusion criteria. Results revealed that the most frequently determined matrix metalloproteinases were MMP-2 and MMP-9, and were found in 54.5% of wounds. MMP-9 was present in more than 50% of the chronic wounds with a range from 37 to 78%. However, metalloproteinases were found in only 20% of acute wounds, and other types of metalloproteinases were also observed (MMP-2 and MMP-3). On the basis of the available evidence, high levels of metalloproteinases have been correlated with significantly delayed wound healing in wounds of a variety of etiologies.

Hard-to-heal diabetic foot ulcers treated using negatively charged polystyrene microspheres: a prospective case series.

OBJECTIVE: To describe the outcomes of a new product based on negatively charged polystyrene microspheres (NCM) technology, in non-responding diabetic foot ulcers (DFU). METHODS: A clinical case series of patients with a hard-to-heal DFU treated with NCM were recruited between March and June 2017 in a specialised diabetic foot unit. DFUs were treated daily with NCM over four weeks, although the health professional could decide to continue NCM treatment in some patients. Cases were followed up for 12 weeks. Wollina score (granulation, colour and consistency tissue), wound area (cm2), percentage reduction and wound closure (%) were measured. RESULTS: A total of 22 ulcers (19 patients) were included, of which three patients (five ulcers) were withdrawn due to adverse events: four infections and one necrosis. None were associated with the product. NCM treatment was completed in 17 ulcers (16 patients). The mean patient age was 61.53±9.57 years. At baseline, mean duration time of the DFU was 7.88±8.65 weeks, the median area was 5.35cm2, the interquartile range (IQR) was 1.45 to 4.65cm2 and positive probe-to-bone test (PTB+) was recorded at 29.4%. After four weeks of treatment, an increase in Wollina score (3.65±2.12 to 5.69±1.18; p=0.000), a 62.2% reduction of the ulcer area (5.35 cm2; IQR: 1.45 to 4.65cm2) to 3.33cm2 (IQR: 0.25 to 1.70cm2; p<0.001) and complete healing in 17.6% of ulcers was observed. The mean time of NCM treatment was 6.2±1.2 weeks. At 12 weeks, 100% achieved complete healing, including those ulcers with PTB+. CONCLUSION: After NCM use, a reactivation of the healing process in non-responding wounds was observed, having a significant improvement in Wollina score as well as reduction of the wounds. Complete healing was achieved in all ulcers at 12 weeks, including PTB+.

Ultrasound-assisted debridement of neuroischaemic diabetic foot ulcers, clinical and microbiological effects: a case series.

OBJECTIVE: To evaluate the clinical and microbiological effects of sequential wound debridement in a case series of neuroischaemic diabetic foot ulcers (DFUs) using an ultrasound-assisted wound debridement (UAW) device. METHOD: A prospective, single-centre study, involving a case series of 24 neuroischaemic DFUs, was conducted to evaluate sequential wound debridement with UAW during a six-week treatment period. Soft tissue punch biopsies were taken every second week of treatment, both before and after wound debridement sessions. Qualitative and quantitative microbiological analysis was performed and wounds were assessed at patient admission, and before and after each debridement procedure. RESULTS: Wound tissue quality scores improved significantly from a mean score of 2.1±1.3 points at patient inclusion, to 5.3±1.7 points (p=0.001). Mean wound sizes were 4.45cm2 (range: 2-12.25cm2) at week zero, and 2.75cm2 (range: 1.67-10.70cm2) at week six (p=0.04). The mean number of bacterial species per culture determined at week zero and at week six was 2.53±1.55 and 1.90±1.16, respectively (p=0.023). Wound debridement resulted in significant decreases in bacterial counts (1.17, 1.31 and 0.77 log units in colony forming units (CFU) for week zero, three and six, respectively). The average bacterial load in tissue samples before and after wound debridement after the six-week treatment was Log 5.55±0.91CFU/g and Log 4.59±0.89CFU/g, respectively (p<0.001). CONCLUSIONS: The study results showed a significant bacterial load reduction in DFU tissue samples as a result of UAW debridement, independent of bacterial species, some of which exhibited antibiotic-resistance. Significant bacterial load reduction was correlated with improved wound conditions and significant reductions of wound size.

What Is the Clinical Utility of the Ankle-Brachial Index in Patients With Diabetic Foot Ulcers and Radiographic Arterial Calcification?

The purpose of this study was to analyze the influence of radiographic arterial calcification (RAC) on the clinical interpretation of ankle-brachial index (ABI) values in patients with diabetic foot ulcers. We analyzed a retrospective clinical database of 60 patients with diabetic foot ulcers from the Diabetic Foot Unit (Complutense University, Madrid, Spain) between January 2012 and March 2014. For each patient, anteroposterior XR-plains were evaluated, and the ABI and toe-brachial index (TBI) were assessed by an experienced clinician. To analyze the correlation among quantitative variables, we applied the Pearson correlation coefficient. Fifty percent (n = 9/18) of our patients with a normal ABI and RAC had a TBI < 0.7 associated with peripheral arterial disease (PAD). In patients with RAC, the prevalence of a normal ABI (72%, 18/25) was higher than in patients without RAC (52%, 11/21). The Pearson correlation coefficient among the ABI and TBI in patients with an ABI < 1.4 (n = 46) was lesser (r = .484, P = .001) than in patients with an ABI < 1.4 but without RAC (n = 21; r = .686, P = .001). ABI values between 0.9 and 1.4 would be falsely considered as normal and could underestimate the prevalence of PAD, especially in patients with neuropathy, diabetic foot ulcers, or RAC.

The best way to reduce reulcerations: if you understand biomechanics of the diabetic foot, you can do it.

Foot ulcer recurrence is still an unresolved issue. Although several therapies have been described for preventing foot ulcers, the rates of reulcerations are very high. Footwear and insoles have been recommended as effective therapies that prevent the development of new ulcers; however, the majority of studies have analyzed their effects in terms of reducing peak plantar pressure rather than ulcer relapse. Knowledge of biomechanical considerations is low, in general, in the team approach to diabetic foot because heterogeneous professionals having competence in recurrence prevention are involved. Assessment of biomechanical alterations define a foot type position; examining foot structure and recording plantar pressure could help in appropriate insole and footwear prescription and design. Patient education and compliance should be taken into consideration for better therapy success. When patients suffer from rigid deformities or have undergone an amputation, surgical offloading should be considered as an alternative.