The financial burden of diabetes-related foot disease in Australia: a systematic review.

BACKGROUND: Diabetes-related foot disease (DFD) is a common, costly, and severe complication of diabetes mellitus. DFD is associated with high rates of morbidity and mortality and poses a significant burden on patients, healthcare systems and society. While the detrimental impact of DFD is widely recognised, the precise financial implications of its management in Australia remain unclear due to inconsistent and inconclusive contemporary data. Therefore, the aim of this review was to identify, summarise and synthesise existing evidence to estimate the costs associated with DFD management in Australia. METHODS: Searches were conducted in MEDLINE, Embase, AMED, CINAHL, Joanna Briggs Institute EBP, and the Cochrane Library from November 2011 to July 2023. Australian studies investigating costs associated with DFD management were eligible for inclusion. Two independent reviewers performed the study selection, data extraction and quality assessment steps. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) checklist was used to assess study quality. A descriptive analysis was performed due to limited existing evidence and large heterogeneity between study populations to conduct meta-analyses. RESULTS: Three economic evaluations were included in the review. One study was rated as 'poor', one as 'very good' and one as 'excellent' when assessed against the CHEERS checklist. The estimated cost of DFD management varied between studies and comparisons were not possible due to the different methodological approaches and data sources. The studies were unable to provide an overall cost of DFD with respect to all aspects of care as they did not capture the multi-faceted level of care throughout the entire patient journey between sectors and over time. CONCLUSION: There is limited contemporary evidence for the costs associated with DFD management within Australia, particularly related to direct costs and resource utilisation. Further research into the economic impact of DFD management is needed to inform optimisation of national service delivery and improve health outcomes for individuals with DFD in Australia. Integrating real-world data on impact of clinical interventions with parallel economic evaluation could be a valuable approach for future research, which would offer a more comprehensive understanding of the clinical and economic outcomes beyond solely model-based evaluations. TRIAL REGISTRATION: PROSPERO Registration No. CRD42022290910.

Efficacy of non-surgical interventions for midfoot osteoarthritis: a systematic review.

This systematic review aims to investigate the efficacy of non-surgical interventions for midfoot osteoarthritis (OA). Key databases and trial registries were searched from inception to 23 February 2023. All trials investigating non-surgical interventions for midfoot OA were included. Quality assessment was performed using the National Institutes of Health Quality Assessment Tool. Outcomes were pain, function, health-related quality of life, and adverse events. Effects (mean differences, standardised mean differences, risk ratios) were calculated where possible for the short (0 to 12 weeks), medium (> 12 to 52 weeks), and long (> 52 weeks) term. Six trials (231 participants) were included (one feasibility trial and five case series) - all were judged to be of poor methodological quality. Two trials reported arch contouring foot orthoses to exert no-to-large effects on pain in the short and medium term, and small-to-very-large effects on function in the short and medium term. Two trials reported shoe stiffening inserts to exert medium-to-huge effects on pain in the short term, and small effects on function in the short term. Two trials of image-guided intra-articular corticosteroid injections reported favourable effects on pain in the short term, small effects on pain and function in the medium term, and minimal long term effects. Two trials reported minor adverse events, and none reported health-related quality of life outcomes. The current evidence suggests that arch contouring foot orthoses, shoe stiffening inserts and corticosteroid injections may be effective for midfoot OA. Rigorous randomised trials are required to evaluate the efficacy of non-surgical interventions for midfoot OA.

Activity and footwear characteristics in people with and without plantar heel pain: A matched cross-sectional observational study.

BACKGROUND: Activity and footwear may be associated with plantar heel pain (PHP), however both factors have rarely been investigated. The aim of this study was to investigate activity and footwear characteristics in PHP while controlling for important confounders. METHOD: This cross-sectional observational study compared 50 participants with PHP to 25 participants without PHP who were matched for age, sex and body mass index. Activity was measured using the Stanford Activity Questionnaire, as well as the number of hours per day participants stood for, and whether they stood on hard floors. Footwear characteristics were measured using the footwear domain of the Foot Health Status Questionnaire (FHSQ), as well as the style of shoe, heel height, and the Shore A hardness value of the heel of the shoe most used. RESULTS: Participants with PHP stood for more than twice as long as participants without PHP (mean difference 3.4 hours, p < 0.001, large effect size). Participants with PHP also reported greater difficulty accessing suitable footwear (FHSQ footwear domain mean difference (MD) 22 points, p = 0.002, large effect size (ES), and they wore harder-heeled shoes (Shore A MD 6.9 units, p = 0.019, medium ES). There were no significant differences for physical activity, whether they stood on hard floors, the style of shoe they wore, or heel height. CONCLUSIONS: Compared to people without PHP, people with PHP stand for more than twice the amount of time each day, have substantial difficulties accessing suitable footwear, and the primary shoes they wear are harder under the heel.

Health-related quality of life is substantially worse in individuals with plantar heel pain.

This study aimed to compare health-related quality of life (HRQoL) in people with and without plantar heel pain (PHP). This was a cross-sectional observational study that compared 50 adult participants with PHP to 25 participants without PHP who were matched for age, sex and body mass index (BMI). HRQoL measures included a generic measure, the Short Form 36 version 2 (SF-36v2), and foot-specific measures, including 100 mm visual analogue scales (VASs) for pain, the Foot Health Status Questionnaire (FHSQ), and the Foot Function Index-Revised (FFI-R). Comparisons in HRQoL between the two groups were conducted using linear regression, with additional adjustment for the comorbidity, osteoarthritis, which was found to be substantially different between the two groups. For generic HRQoL, participants with PHP scored worse in the SF-36v2 physical component summary score (p < 0.001, large effect size), but there was no difference in the mental component summary score (p = 0.690, very small effect size). Specifically, physical function (p < 0.001, very large effect size), role physical (p < 0.001, large effect size) and bodily pain (p < 0.001, large effect size) in the physical component section were worse in those with PHP. For foot-specific HRQoL, participants with PHP also scored worse in the VASs, the FHSQ and the FFI-R (p ≤ 0.005, huge effect sizes for all domains, except FHSQ footwear, which was large effect size, and FFR-R stiffness, activity limitation, and social issues, which were very large effect sizes). After accounting for age, sex, BMI and osteoarthritis, adults with PHP have poorer generic and foot-specific HRQoL.

Australian guideline on prevention of foot ulceration: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease.

BACKGROUND: There are no current Australian guidelines on the prevention of diabetes-related foot ulceration (DFU). A national expert panel aimed to systematically identify and adapt suitable international guidelines to the Australian context to create new Australian evidence-based guidelines on prevention of first-ever and/or recurrent DFU. These guidelines will include for the first-time considerations for rural and remote, and Aboriginal and Torres Strait Islander peoples. METHODS: The National Health and Medical Research Council procedures were followed to adapt suitable international guidelines on DFU prevention to the Australian health context. This included a search of public databases after which the International Working Group on the Diabetic Foot (IWGDF) prevention guideline was deemed the most appropriate for adaptation. The 16 IWGDF prevention recommendations were assessed using the ADAPTE and GRADE systems to decide if they should be adopted, adapted or excluded for the new Australian guideline. The quality of evidence and strength of recommendation ratings were re-evaluated with reference to the Australian context. This guideline underwent public consultation, further revision, and approval by national peak bodies. RESULTS: Of the 16 original IWGDF prevention recommendations, nine were adopted, six were adapted and one was excluded. It is recommended that all people at increased risk of DFU are assessed at intervals corresponding to the IWGDF risk ratings. For those at increased risk, structured education about appropriate foot protection, inspection, footwear, weight-bearing activities, and foot self-care is recommended. Prescription of orthotic interventions and/or medical grade footwear, providing integrated foot care, and self-monitoring of foot skin temperatures (contingent on validated, user-friendly and affordable systems becoming available in Australia) may also assist in preventing DFU. If the above recommended non-surgical treatment fails, the use of various surgical interventions for the prevention of DFU can be considered. CONCLUSIONS: This new Australian evidence-based guideline on prevention of DFU, endorsed by 10 national peak bodies, provides specific recommendations for relevant health professionals and consumers in the Australian context to prevent DFU. Following these recommendations should achieve better DFU prevention outcomes in Australia.

Medical imaging for plantar heel pain: a systematic review and meta-analysis.

BACKGROUND: Medical imaging can be used to assist with the diagnosis of plantar heel pain. The aim of this study was to synthesise medical imaging features associated with plantar heel pain. METHODS: This systematic review and meta-analysis conducted searches in MEDLINE, CINAHL, SPORTDiscus, Embase and the Cochrane Library from inception to 12th February 2021. Peer-reviewed articles of cross-sectional observational studies written in English that compared medical imaging findings in adult participants with plantar heel pain to control participants without plantar heel pain were included. Study quality and risk of bias was assessed using the National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies. Sensitivity analyses were conducted where appropriate to account for studies that used unblinded assessors. RESULTS: Forty-two studies (2928 participants) were identified and included in analyses. Only 21% of studies were rated 'good' on quality assessment. Imaging features associated with plantar heel pain included a thickened plantar fascia (on ultrasound and MRI), abnormalities of the plantar fascia (on ultrasound and MRI), abnormalities of adjacent tissue such as a thickened loaded plantar heel fat pad (on ultrasound), and a plantar calcaneal spur (on x-ray). In addition, there is some evidence from more than one study that there is increased hyperaemia within the fascia (on power Doppler ultrasound) and abnormalities of bone in the calcaneus (increased uptake on technetium-99 m bone scan and bone marrow oedema on MRI). CONCLUSIONS: People with plantar heel pain are more likely to have a thickened plantar fascia, abnormal plantar fascia tissue, a thicker loaded plantar heel fat pad, and a plantar calcaneal spur. In addition, there is some evidence of hyperaemia within the plantar fascia and abnormalities of the calcaneus. Whilst these medical imaging features may aid with diagnosis, additional high-quality studies investigating medical imaging findings for some of these imaging features would be worthwhile to improve the precision of these findings and determine their clinical relevance.

Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study.

BACKGROUND: Charcot neuroarthropathy (Charcot foot) is a highly destructive joint disease of the foot and ankle. If there is delayed diagnosis and treatment, it can lead to gross deformity, instability, recurrent ulceration and/or amputation. Total contact casting (TCC) is a treatment commonly used to immobilise the foot and ankle to prevent trauma, further destruction and preserve the foot structure during the inflammatory phase. At present, there is limited Australian data regarding the duration of TCC treatment for resolution of acute Charcot foot, and whether there are any patient and clinical factors affecting its duration. Therefore, this study aimed to address these deficiencies. METHODS: This study presents a retrospective analysis of 27 patients with acute Charcot foot attending for TCC treatment at a high-risk foot service (HRFS) in a large metropolitan health network in Melbourne, Australia. Over a three-year period, data were retrospectively collected by reviewing hospital medical records for clinical, demographic, medical imaging and foot examination information. To explore between-group differences, independent samples t-tests, Mann-Whitney U tests, Chi-square tests, and/or Fisher's exact tests were calculated depending on data type. To evaluate associations between recorded variables and duration of TCC treatment, mean differences, odds ratios (OR) and 95% confidence intervals were calculated. RESULTS: Mean age was 57.9 (SD, 12.6) years, 66.7% were male, 88.9% had diabetes, 96.3% had peripheral neuropathy, and 33.3% had peripheral arterial disease. Charcot misdiagnosis occurred in 63.0% of participants, and signs and symptoms consistent with acute Charcot foot were present for a median of 2.0 (IQR, 1.0 to 6.0) months prior to presenting or being referred to the HRFS. All participants had stage 1 Charcot foot. Of these, the majority were located in the tarsometatarsal joints (44.4%) or midfoot (40.7%) and were triggered by an ulcer or traumatic injury (85.2%). The median TCC duration for resolution of acute Charcot foot was 4.3 (IQR, 2.7 to 7.8) months, with an overall complication rate of 5% per cast. Skin rubbing/irritation (40.7%) and asymmetry pain (22.2%) were the most common TCC complications. Osteoarthritis was significantly associated with a TCC duration of more than 4 months (OR, 6.00). Post TCC treatment, 48.1% returned to footwear with custom foot orthoses, 25.9% used a life-long Charcot Restraint Orthotic Walker, and 22.2% had soft tissue or bone reconstructive surgery. There were no Charcot recurrences, however, contralateral Charcot occurred in 3 (11.1%) participants. CONCLUSIONS: The median TCC duration for resolution of acute Charcot foot was 4 months, which is shorter or comparable to data reported in the United Kingdom, United States, Europe, and other Asia Pacific countries. Osteoarthritis was significantly associated with a longer TCC duration. The findings from this study may assist clinicians in providing patient education, managing expectations and improving adherence to TCC treatment for acute Charcot neuroarthropathy cases in Australia.

Clinical measures of foot posture and ankle joint dorsiflexion do not differ in adults with and without plantar heel pain.

Foot posture and ankle joint dorsiflexion have long been proposed to be risk factors for plantar heel pain, however body mass may be a confounder when investigating these factors. The aim of this study was to determine if clinical measures of foot posture and ankle joint dorsiflexion differ in adults with and without plantar heel pain after accounting for body mass. This was a cross-sectional observational study that compared 50 participants with plantar heel pain to 25 control participants without plantar heel pain who were matched for age, sex and body mass index. Foot posture was assessed using the Foot Posture Index and the Arch Index. Ankle joint dorsiflexion was assessed with a weightbearing lunge test with the knee extended and with the knee flexed. No significant differences (P < 0.05) were found between the groups for foot posture, whether measured with the Foot Posture Index or the Arch Index. Similarly, no significant differences were found in the weightbearing lunge test whether measured with the knee extended or with the knee flexed. Clinical measures of foot posture and ankle joint dorsiflexion do not differ in adults with and without plantar heel pain when body mass is accounted for. Therefore, clinicians should not focus exclusively on foot posture and ankle dorsiflexion and ignore the contribution of overweight or obesity.

Infrared dermal thermometry is highly reliable in the assessment of patients with Charcot neuroarthropathy.

BACKGROUND: Charcot neuroarthropathy (Charcot foot) is a serious limb-threatening complication most commonly seen in individuals with diabetic peripheral neuropathy. Although dermal thermometry is widely used by clinicians to assist in the diagnosis, monitoring, and management of the disease, there is limited high-quality evidence to support its reliability. Therefore, this study investigated the intra-rater and inter-rater reliability of infrared dermal thermometry in patients with Charcot neuroarthropathy. METHODS: We collected clinical, demographic, health status, and foot examination information on 32 adults with Charcot neuroarthropathy from a metropolitan high-risk foot service in Melbourne, Australia. Infrared dermal thermometry assessments were conducted by two independent raters at 10 anatomical sites of the Charcot foot using both a (i) touch and (ii) non-touch technique. Intra-rater and inter-rater reliability of the two assessment techniques were evaluated using intra-class correlation coefficients (ICCs), limits of agreement, standard error of measurement, and minimal detectable change statistics. RESULTS: Mean age was 59.9 (standard deviation [SD], 10.5) years, 68.8% were male, average duration of diabetes was 20.6 (SD, 15.1) years, 71.9% had type 2 diabetes, 93.8% had peripheral neuropathy, 43.8% had peripheral arterial disease, and 50% had previous foot ulceration. Charcot foot most commonly affected the tarsometatarsal joints (38.9%), had a median duration of 2.8 (interquartile range [IQR], 1.3 to 5.9) months, and a large proportion were being treated with total contact casting (69.4%). Overall, there was good to excellent intra-rater and inter-rater relative reliability for the 'touch' technique (ICC, 0.87 to 0.99; ICC, 0.83 to 0.98, respectively), and excellent intra-rater and inter-rater relative reliability for the 'non-touch' technique (ICC, 0.93 to 0.99; ICC, 0.91 to 0.99, respectively). In addition, measurement error was found to be relatively low across the 10 anatomical sites. CONCLUSIONS: Infrared dermal thermometry can now be used with confidence in clinical and research settings to provide a reliable assessment of skin temperature in patients with Charcot neuroarthropathy, using either a touch or non-touch technique at 10 commonly used testing sites. A non-touch technique, however, was observed to have slightly higher reliability indicating it may be associated with less measurement error than the touch technique.

Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: a prospective observational cohort study.

BACKGROUND: Dialysis patients experience high rates of foot ulceration. Although risk factors for ulceration have been extensively studied in patients with diabetes, there is limited high-quality, longitudinal evidence in the dialysis population. Therefore, this study investigated risk factors for foot ulceration in a stable dialysis cohort. METHODS: We prospectively collected clinical, demographic, health status, and foot examination information on 450 adults with end-stage renal disease from satellite and home-therapy dialysis units in Melbourne, Australia over 12 months. The primary outcome was foot ulceration. Cox proportional hazard modelling and multinomial regression were used to investigate risk factors. RESULTS: Among 450 dialysis patients (mean age, 67.5 years; 64.7% male; 94% hemodialysis; 50.2% diabetes), new cases of foot ulceration were identified in 81 (18%) participants. Overall, risk factors for foot ulceration were neuropathy (HR 3.02; 95% CI 1.48 to 6.15) and previous ulceration (HR 2.86; CI 1.53 to 5.34). In those without history of ulceration, nail pathology (RR 3.85; CI 1.08 to 13.75) and neuropathy (RR 2.66; CI 1.04 to 6.82) were risk factors. In those with history of ulceration, neuropathy (RR 11.23; CI 3.16 to 39.87), peripheral arterial disease (RR 7.15; CI 2.24 to 22.82) and cerebrovascular disease (RR 2.08; CI 1.04 to 4.16) were risk factors. There were 12 (2.7%) new amputations, 96 (21.3%) infections, 24 (5.3%) revascularizations, 42 (9.3%) foot-related hospitalizations, and 52 (11.6%) deaths. CONCLUSIONS: Neuropathy and previous ulceration are major risk factors for foot ulceration in dialysis patients. Risk factors differ between those with and without prior ulceration. The risk factors identified will help to reduce the incidence of ulceration and its associated complications.

Evaluating the Introduction of an Allied Health Clinical Research Office at a Health Service: Effects on Research Participation, Interest, and Experience of Allied Health Professionals.

Following the introduction of an allied health clinical research office at a large metropolitan health service, we aimed to measure change in self-reported research participation, interest and experience of allied health professionals. METHODS: Allied health professionals were surveyed using the Research Spider tool in 2015 (n=245), and the results were compared to a similar survey completed in 2007 at the same health service (n=132). RESULTS: Overall, allied health professionals rated themselves as having "some research interest" and "little research experience," with no significant difference from 2007 to 2015. Allied health professionals with at least some research interest reported increased experience in critically reviewing literature (p=0.045) and finding relevant literature (p=0.009) and a trend to increased experience of publishing research (p=0.059) in 2015 compared with 2007. The proportion of allied health professionals who classified themselves as participating in research had increased from 41% in 2007 to 51% in 2015 (p=0.028). CONCLUSIONS: The introduction of an allied health clinical research office has been associated with increased participation in research with some improvements in research experience for those with at least some interest in research. Despite these positive changes, most allied health professionals at this health service still report little research experience and only some interest in research.

Factors associated with foot ulceration and amputation in adults on dialysis: a cross-sectional observational study.

BACKGROUND: Adults on dialysis are at increased risk of foot ulceration, which commonly precedes more serious lower limb complications, including amputation. Limited data exist regarding the prevalence and factors associated with foot disease in this population. Hence, this study set out to investigate factors associated with foot ulceration and amputation in a dialysis cohort. METHODS: This study presents a cross-sectional analysis of baseline data from a multi-center prospective cohort study. We recruited 450 adults with end-stage renal disease on dialysis from multiple satellite and home-therapy dialysis units in Melbourne, Australia from January to December 2014. Data collection consisted of a participant interview, medical record review, health-status questionnaire and non-invasive foot examination. Logistic regression analyses were conducted to evaluate associations between screened variables and study outcomes. RESULTS: Mean age was 67.5 (SD, 13.2) years, 64.7% were male, 94% were on hemodialysis, median dialysis duration was 36.9 (IQR, 16.6 to 70.1) months, and 50.2% had diabetes. There was a high prevalence of previous ulceration (21.6%) and amputation (10.2%), 10% had current foot ulceration, and 50% had neuropathy and/or peripheral arterial disease. Factors associated with foot ulceration were previous amputation (OR, 10.19), peripheral arterial disease (OR, 6.16) and serum albumin (OR, 0.87); whereas previous and/or current ulceration (OR, 167.24 and 7.49, respectively) and foot deformity (OR, 15.28) were associated with amputation. CONCLUSIONS: Dialysis patients have a high burden of lower limb complications. There are markedly higher risks of foot ulceration and/or amputation in those with previous and/or current ulceration, previous amputation, peripheral arterial disease, lower serum albumin, and foot deformity. Although not a major risk factor, diabetes in men was an important effect modifier for risk of ulceration.

Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: study protocol for a prospective observational cohort study.

BACKGROUND: Adults with end-stage renal disease treated with dialysis experience a high burden of foot ulceration and lower extremity amputation. However, the risk factors for foot ulceration in the dialysis population are incompletely understood due to the lack of high-quality prospective evidence. This article outlines the design of a prospective observational cohort study, which aims to investigate the risk factors for foot ulceration in adults on dialysis. METHODS/DESIGN: This study will recruit 430 participants with end-stage renal disease on dialysis from satellite and home-therapy dialysis units across multiple health organisations in Melbourne, Victoria, Australia. Data collection at baseline will include a participant interview, medical record review, completion of a health-status questionnaire and a non-invasive foot assessment. Twenty participants will also be recruited to a reliability study to evaluate the reproducibility of testing procedures. Primary outcome data includes: new foot ulcer(s). Secondary outcome data includes: number of new foot ulcers, time to onset of new foot ulcer(s), new lower extremity amputation(s), episodes of infection of the foot or lower extremity, episodes of osteomyelitis, foot-related hospitalisations, revascularisation procedure(s) of the lower extremity, new podiatry interventions, kidney transplantation, and mortality. Participants will be assessed at baseline, and at 12 months they will be evaluated for the primary and secondary outcomes. Multivariate Cox proportional hazards models will be used to assess predictors of new foot ulceration and time to event secondary outcomes. Logistic regression will be used for binary outcomes including prevalence of foot ulcerations. DISCUSSION: This is the first multi-centre prospective observational cohort study to investigate risk factors for foot ulceration in adults with end-stage renal disease on dialysis. This study will improve on prior studies by using prospective methods, multi-centre recruitment, statistical methods to control for confounding variables, and a pre-specified sample size estimation. The findings can inform the design of future trials evaluating the effectiveness of clinical interventions, which may lead to improved patient outcomes in the dialysis setting.

Tendon lengthening and fascia release for healing and preventing diabetic foot ulcers: a systematic review and meta-analysis.

BACKGROUND: Diabetic foot ulcers have a devastating impact on an individual's health-related quality of life and functional status. Additionally, diabetic foot ulcers impose a significant economic burden on our health care systems as a result of complications such as infection, hospitalisation and amputation. The current gold standard treatment for diabetic foot ulcers is total contact casting. However, the rate of ulcer recurrence is high, indicating the need for more effective long-term treatment options. Therefore, the aim of this study was to systematically identify, critique and evaluate all literature investigating the effectiveness of Achilles tendon lengthening, gastrocnemius recession and selective plantar fascia release in healing and preventing diabetic foot ulcers. REVIEW: Searches were conducted in MEDLINE, CINAHL, AMED, EMBASE and The Cochrane Library from the earliest available date to November 2014. Methodological quality of included studies was assessed using the Downs and Black checklist. Data from randomised-controlled trials were analysed using random effects meta-analysis. For all other studies, data were analysed descriptively. Eleven studies (614 participants) were included in the review, with a median sample size of 29 participants. Meta-analysis of two randomised-controlled trials found that there was no statistically significant difference between Achilles tendon lengthening or gastrocnemius recession and total contact casting for time to healing of diabetic foot ulcers (mean difference, MD, 8.22 days; 95 % CI, -18.99 to 35.43; P = 0.55; I (2) = 34 %) and the rate of ulcers healed (risk ratio, RR, 1.06; 95 % CI, 0.94 to 1.20; P = 0.34; I (2) = 41 %). The rate of ulcer recurrence was significantly lower following Achilles tendon lengthening or gastrocnemius recession than total contact casting (RR, 0.45; 95 % CI, 0.28 to 0.72; P < 0.001; I (2) = 0 %). CONCLUSIONS: Achilles tendon lengthening and gastrocnemius recession appear to be effective surgical treatments for healing diabetic foot ulcers. The rate of ulcer recurrence was lower following Achilles tendon lengthening or gastrocnemius recession procedures compared to total contact casting treatment alone. Therefore, these surgical procedures may provide viable treatment options for the management and prevention of diabetic foot ulcers. Further rigorous randomised-controlled trials with longer follow-up are required to determine the long-term effectiveness and safety of these procedures.

Risk factors for foot ulceration and lower extremity amputation in adults with end-stage renal disease on dialysis: a systematic review and meta-analysis.

BACKGROUND: Adults with end-stage renal disease are at increased risk of foot ulceration and lower extremity amputation. However, the central determinants of lower limb injury and loss are incompletely understood. METHODS: We conducted a systematic review of non-randomized studies that quantified the major risk factors for foot ulceration and amputation in adults treated with dialysis and analysed patient populations in which risks were greatest. Random-effects meta-analysis was used to generate summary estimates. RESULTS: Thirty studies (48 566 participants) were identified. Risk factors for foot ulceration and amputation included previous foot ulceration (odds ratios, OR, 17.56 and 70.13), peripheral arterial disease (OR, 7.52 and 9.12), diabetes (OR, 3.76 and 7.48), peripheral neuropathy (OR, 3.24 and 3.36) and coronary artery disease (OR, 3.92 and 2.49). Participants with foot ulceration or amputation had experienced a longer duration of diabetes (mean difference, MD, 4.04 and 6.07 years) and had lower serum albumin levels (MD, -0.23 and -0.13 g/dL). Risk factors for foot ulceration also included retinopathy (OR, 3.03), previous amputation (OR, 15.50) and higher serum phosphorus levels (MD, 0.40 mg/dL), while risk factors for amputation also included male sex (OR, 1.50), current smoking (OR, 2.26) and higher glycated haemoglobin levels (MD, 0.75%). CONCLUSIONS: Dialysis patients who have markedly higher risks of ulceration or amputation include those with previous foot ulceration or amputation, peripheral neuropathy, diabetes or macrovascular disease. The temporal relationship between these risk factors and the development of foot ulceration and/or limb loss is uncertain and requires further study. Stable estimates of the key risk factors for ulceration and amputation can inform the design of future trials investigating clinical interventions to reduce the burden of lower limb disease in the dialysis population.