Randomized Double-blind Cost-effectiveness Comparison of Two 10% Urea Creams in Patients with Diabetic Foot Syndrome.

OBJECTIVE: To evaluate the cost-effectiveness of two 10% urea creams in patients with diabetic foot syndrome. METHODS: This was a prospective, longitudinal, single-center, randomized, double-blind, prospective clinical trial that evaluated the skin quality of 20 feet belonging to 10 patients with diabetic foot syndrome after the application of two 10% urea creams purchased from pharmacies and supermarkets. RESULTS: At follow-up, 19 (95%) of the participants' feet showed improved skin quality, irrespective of the cream applied. On visual inspection, participants had a decreased presence of xerosis, hyperkeratosis, and preulcerative signs such as subkeratotic bruising and areas of redness on the dorsum of the toes. At the 3-month follow-up, nine (90%) of the participants stated that they had continued to apply the cream as a method of self-management to prevent complications. CONCLUSIONS: Creams containing 10% urea purchased in supermarkets improve foot skin quality in patients with diabetic foot syndrome, regardless of their cost. Based on these findings, the authors recommend creams containing 10% urea as a self-management tool for patients with diabetic foot syndrome.

Effectiveness of Off-Loading Devices in Patients With Active Diabetic Foot Ulcer: A Systematic Review.

A systematic review of the effectiveness of off-loading in the diabetic foot was done. Searches were conducted in October 2022 using the PubMed and Scielo databases. Randomized clinical trials or controlled clinical trials were included. Two authors performed the study selection and data extraction, and any discrepancies between the 2 reviewers were resolved through discussion with a third reviewer. Fourteen papers met the selection criteria with 822 patients included, but the sample sizes in all studies were small. Most of the published studies were done in European countries. Total contact cast was the most effective off-loading. The present review studies the effectiveness of off-loading systems in patients with diabetic foot ulcer, as well as different off-loading methods, with total contact cast proving to be the gold standard, despite its adverse effects.

Variables That Could Influence Healing Time in Patients with Diabetic Foot Osteomyelitis.

AIM: To compare the healing time in patients with diabetic foot osteomyelitis according to the presence or absence of clinical signs of infection, variation of blood parameters, the presence of different radiological signs, and the treatment received for the management of osteomyelitis. METHODS: A prospective observational study was carried out in a specialised Diabetic Foot Unit between November 2014 and November 2018. A total of 116 patients with osteomyelitis were included in the study (treated by either a surgical or medical approach). During the baseline visit, we assessed the diagnosis of osteomyelitis, demographic characteristics and medical history, vascular and neurological examination, clinical signs of infection, increased blood parameters, radiological signs of osteomyelitis, and the treatment to manage osteomyelitis. We analysed the association between the presence of clinical signs of infection, variation of blood parameters, presence of radiological signs, and treatment received for management of osteomyelitis with the healing time. RESULTS: The mean time to ulcer healing was 15.8 ± 9.7 weeks. Concerning healing times, we did not find an association with the presence of clinical signs of infection or with the increase in blood parameters, except in the case of eosinophils, which with higher values appear to increase the healing time (U = 66, z = -2.880, p = 0.004). Likewise, no relationship has been found between healing time and the appearance of the different radiological signs of osteomyelitis, nor depending on the treatment administered for the management of osteomyelitis. CONCLUSION: High levels of eosinophils are associated with a longer healing time of diabetic foot ulcers complicated with osteomyelitis, finding no other factors related to increased healing time.

Punch Grafting for the Management of Hard-to-Heal Diabetic Foot Ulcers: A Prospective Case Series.

Punch grafting is an alternative treatment to enhance wound healing which has been associated with promising clinical outcomes in various leg and foot wound types. We aimed to evaluate the clinical outcomes of punch grafting as a treatment for hard-to-heal diabetic foot ulcers (DFUs). Six patients with chronic neuropathic or neuroischemic DFUs with more than 6 months of evolution not responding to conventional treatment were included in a prospective case series between May 2017 and December 2020. All patients were previously debrided using an ultrasound-assisted wound debridement and then, grafted with 4 to 6 mm punch from the donor site that was in all cases the anterolateral aspect of the thigh. All patients were followed up weekly until wound healing. Four (66.7%) DFUs were located in the heel, 1 (16.7%) in the dorsal aspect of the foot and 1 (16.7%) in the Achilles tendon. The median evolution time was 172 (interquartile range [IQR], 25th-75th; 44-276) weeks with a median area of 5.9 (IQR; 1.87-37.12) cm2 before grafting. Complete epithelization was achieved in 3 (50%) patients at 12 weeks follow-up period with a mean time of 5.67 ± 2.88 weeks. Two of the remaining patients achieved wound healing at 32 and 24 weeks, respectively, and 1 patient showed punch graft unsuccessful in adhering. The median time of wound healing of all patients included in the study was 9.00 (IQR; 4.00-28.00) weeks. The wound area reduction (WAR) at 4 weeks was 38.66% and WAR at 12 weeks was 88.56%. No adverse effects related to the ulcer were registered through the follow-up period. Autologous punch graft is an easy procedure that promotes healing, achieving wound closure in chronic DFUs representing an alternative of treatment for hard-to-heal DFUs in which conservative treatment has been unsuccessful.

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.

Are Digital Arthroplasty and Arthrodesis Useful and Safe Surgical Techniques for the Management of Patients with Diabetic Foot?

OBJECTIVE: To analyze and compare the development of short- and long-term complications in patients with diabetic foot after digital arthroplasty or arthrodesis. METHODS: The authors reviewed patient records from January 2017 to March 2020. Patients were treated by digital arthroplasty or arthrodesis to correct toe deformity (elective or prophylactic surgery), achieve ulcer healing in toes (curative surgery), or manage toe infection (emergent surgery). During 1-year follow-up, researchers registered short- and long-term complications. Researchers analyzed the association between the type of surgery and the development of short- and long-term complications. RESULTS: Forty-four patients (83.0%) received arthroplasty, and nine (17.0%) received arthrodesis. The mean time to heal from ulcers was 5.2 ± 5.2 weeks. A significant association was observed between arthrodesis and the development of long-term complications (P = .044; odds ratio, 5.1; 95% confidence interval, 0.9-27.2). No differences were observed between type of surgery and short- or long-term complications. Moreover, both short- and long-term complications were related to longer time to heal (respectively, 7.6 ± 6.0 vs 2.1 ± 0.5 weeks, P < .001; and 6.3 ± 6.2 vs 4.2 ± 4.0 weeks, P = .039). CONCLUSIONS: Digital arthroplasty or arthrodesis are good options for managing patients with diabetic foot who require digital deformity correction to achieve digital ulcer healing or management of diabetic foot infection in phalanges.

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.

Predictive Radiographic Values for Foot Ulceration in Persons with Charcot Foot Divided by Lateral or Medial Midfoot Deformity.

BACKGROUND: To identify differences in radiographic outcomes in weight-bearing lateral X-ray to predict the probability of ulceration in patients with midfoot Charcot neuroarthropathy (CN) differentiated by lateral and medial column deformities. METHODS: Thirty-five patients who suffered from CN midfoot deformity participated in this 1 year prospective study in a specialized diabetic foot unit. Lateral talar-first metatarsal angle, calcaneal pitch, and cuboid height were performed by digital radiographs in the weight-bearing lateral view. Patients were followed up for 1 year or until an ulcer ulceration event occurred in the midfoot region. RESULTS: ROC analyses showed that all patients with medial pattern deformity that developed a midfoot ulcer had a lateral talar-first metatarsal angle greater (negative) than -27.5 degrees (°). All patients with lateral pattern deformity that developed a midfoot ulcer had a calcaneal pitch greater (more negative) than -5° and a cuboid height greater (more negative) than -1.5°. CONCLUSIONS: Lateral talar-first metatarsal angle was the greatest predictor of midfoot ulceration, with greater than -27.5° measurement correlating with ulceration occurrence in patients with medial deformity. Calcaneal pitch and cuboid height were the greatest predictors of midfoot ulceration with greater than -5 and -1.5°, respectively in patients with CN lateral deformity.

Evaluation of Adherence to the Oral Antibiotic Treatment in Patients With Diabetic Foot Infection.

Introduction: The knowledge about level of adherence to oral antibiotic treatment in diabetic patients with ulcer infection could be essential as a method of evaluation/monitoring of conservative treatment. Aim: To assess the adherence to oral antibiotic treatment in outpatients with diabetic foot infection (soft tissue vs. osteomyelitis) by 8-item structured, self-reported medication adherence scale. Methods: cross-sectional study was carried out with 46 consecutive patients who had diabetic foot infection (soft tissue or bone infection) and required antibiotic oral treatment at outpatient clinical setting. Medication adherence was tested using the Spanish version of the validated eight-item self-report MMAS-8. Results: patients with diabetic ulcer infection, had well level of adherence to antibiotic medication (7 ± 1.2 vs. 7.4 ± 1.5). Patients with lower level of adherence had lower level of satisfaction with the antibiotic medication. The profile of the patients with lower level of adherence were patients with primary level of education and patient who required more help to take the medication. Conclusion: Patients with diabetic foot infection demonstrated well level of adherence to antibiotic medication, independently of type of infection (soft tissue vs. osteomyelitis) by 8-item structured, self-reported medication adherence scale.

Long-Term Complications after Surgical or Medical Treatment of Predominantly Forefoot Diabetic Foot Osteomyelitis: 1 Year Follow Up.

AIM: To compare long-term complications according to the treatment received for management of diabetic foot osteomyelitis (surgical or medical) at 1 year follow up. DESIGN AND PARTICIPANTS: A prospective observational study was conducted involving 116 patients with diabetic foot osteomyelitis. The patients received surgical or medical treatment based on the principles described in the literature. To register the development of a complication, both groups of treatments were followed-up 1 year after the ulcer had healed. RESULTS: Ninety-six (82.8%) patients received surgical treatment and 20 (17.2%) medical treatment. No differences were found in the time to healing between both groups of treatment, 15.7 ± 9.2 weeks in the surgical group versus 16.4 ± 12.1 weeks in the medical group; p = 0.103. During follow up, 85 (73.3%) patients developed complications without differences between both groups, 68 (70.8%) in the surgical group versus 17 (85%) in the medical group (p = 0.193). The most common complication in both groups was re-ulceration. We did not observe significant differences comparing complication-free time survival between both treatments (p = 0.665). CONCLUSION: The onset of complications after healing in patients who suffered from diabetic foot osteomyelitis was not associated with the treatment received. Surgical and medical approaches to the management of diabetic foot osteomyelitis produced similar results in long-term follow up.

Medical Versus Surgical Treatment for the Management of Diabetic Foot Osteomyelitis: A Systematic Review.

A systematic review and quality assessment was performed to assess the management of diabetic foot osteomyelitis by medical or surgical treatment. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used. All selected studies were evaluated using the Cochrane Risk of Bias Tool to assess the risk of bias for randomized controlled trials. The literature was revised using PubMed (Medline) and Embase (Elsevier) up to September 2020 to identify clinical trials assessing medical or surgical treatment to manage diabetic foot osteomyelitis. A total of six clinical trials that met our inclusion criteria, with a total of 308 participants. Healing rate, complete closure of the wound, and type of complications were the outcomes evaluated. Risk of bias assessment showed that only two of the six clinical trials included in the systematic review had a low risk of bias. Based on our findings, we believe that the management of diabetic foot osteomyelitis remains challenging. There are few high-quality clinical trials that both stratify clinical presentations and compare these treatments. We conclude that the available evidence is insufficient to identify the best option to cure diabetic foot osteomyelitis.

Diagnostic Accuracy of Bone Culture Versus Biopsy in Diabetic Foot Osteomyelitis.

OBJECTIVE: To compare the diagnostic accuracy of bone culture (microbiology) and biopsy (histology) in patients with acute or chronic diabetic foot osteomyelitis (DFO). METHODS: This cross-sectional study involved patients for whom providers had a clinical suspicion of DFO. Two bone samples were taken: one for microbiologic testing and another for histologic testing. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio were calculated for bone culture results in relation to the probability of DFO diagnosis. RESULTS: Fifty-two patients were included; 69% had positive bone culture results, and 90.4% had positive histology results (P = .013), and of those 90.4%, 25.5% had acute and 74.5% had chronic DFO. The sensitivity of the microbiologic bone culture result was 0.70, the specificity was 0.40, the positive predictive value was 0.92, and the negative predictive value was 0.13. CONCLUSIONS: Histology provides more accurate diagnosis of DFO than microbiology, especially for patients with chronic DFO. These patients could be underdiagnosed because of false-negative results provided by bone culture. Providers should perform both tests to confirm the presence of DFO.

Conservative surgery for chronic diabetic foot osteomyelitis: Procedures and recommendations.

Osteomyelitis (OM) is the most frequent infection associated with diabetic foot ulcers (DFU) that typically involve the forefoot, the most common location of DFU. Conservative surgical procedures could be attractive alternative that reduces minor and major amputations and avoid future recurrence thus preserving the functionally of the foot. This review aimed to analyze and describe the current evidence on conservative diabetic foot osteomyelitis (DFO) surgical procedures depending on DFU location and indications. A narrative revision of the evidence was carried out by searching Medline through PubMed databases from inception to late July 2020 to identify retrospective, prospective, and randomized controlled trials pertaining to conservative DFO procedures on the forefoot. Seven types of conservative surgical procedures for DFO treatment in the forefoot are described in this review: (1) partial or total distal phalangectomy, (2) arthroplasty of the proximal or distal interphalangeal joint, (3) distal Syme amputation, (4) percutaneous flexor tenotomy, (5) sesamoidectomy, (6) arthroplasty of the metatarsophalangeal joint, and (7) metatarsal head resection. When indicated, conservative surgery for DFUs in patients with chronic forefoot OM is a safe and effective option that increases the chances of healing and reduces the possibility of limb loss and death compared with radical amputation procedures. Since a lack of sufficient evidence supporting this procedure exists, future investigations should be focused on the random clinical trial (RCT) design. The results of prospective trials could help surgeons select the appropriate procedure in each case in order to minimize complications.

Evolution of the TcPO2 values following hyperoxygenated fatty acids emulsion application in patients with diabetic foot disease: results of a clinical trial.

OBJECTIVE: The use of emollients to lubricate dry skin to prevent diabetic foot ulcers (DFUs), especially in neuroischaemic feet, has been recommended. This study analyses the effect of daily topical application of hyperoxygenated fatty acids emulsion on transcutaneous oxygen pressure (TcPO2) in the feet of neuropathic and neuroischaemic patients with diabetes. METHOD: Patients with diabetes and no active foot ulcer were included in this longitudinal, prospective, non-comparative clinical trial. The evolution of TcPO2 (mmHg) values after the application of the tested emulsion (Corpitol Emulsion, Laboratoires Urgo Medical, France) was evaluated for a three-month period. Modifications of skin features (skin dryness, skin shedding and skin colour) were also analysed. TcPO2 was performed using a TCM400 device (Radiometer, Denmark). RESULTS: A total of 50 patients were included in the study. Patients with neuroischaemia showed a significant increase in TcPO2 values (35.69±13.88mmHg) after two months' application of the tested emulsion that remained at month three (day 60: 42.34±10.98mmHg; p=0.006; day 90: 41.62±10.88mmHg; p=0.011). Skin dryness and shedding showed an improvement from baseline to the end of the study in both groups, secondary to the use of the tested emulsion (p<0.001 and p<0.001, respectively). Skin colour also showed differences from baseline to the final visit in the neuroischaemic patients (p=0.029). Patients with neuropathy did not show any change in skin colour from baseline to the final visit. CONCLUSIONS: Analysis of the use of the tested emulsion showed an increase in TcPO2 and an improvement in skin trophism in patients with neuroischaemic foot.

Topical treatment for plantar warts: A systematic review.

There are a wide variety of treatments for plantar warts, but none has been shown to be effective in all patients. We aimed to perform a systematic review of the efficacy of different topical treatments on plantar warts. Systematic electronic searches (Pubmed, Cochrane Library, Embase, and Web of Science) were conducted in April 2020. Meta-analyses, systematic reviews, and retrospective or prospective clinical trials of the effects of topical and nonsurgical treatments of plantar warts were included. Two authors performed the study selection and data extraction. Any discrepancies between the two reviewers were discussed with a third reviewer. Forty-four studies were included. The average cure rates of the most frequent treatments were variable across the studies: cryotherapy (45.61%), salicylic acid (13.6%), cantharidin-podophyllin-salicylic acid formulation (97.82%), laser (79.36%), topical antivirals (72.45%), intralesional bleomycin (83.37%), and intralesional immunotherapy (68.14%). Twenty-two studies (50%) had a level of evidence 1b and grade of recommendation A, five studies (11.4%) had a level of evidence 2b and grade of recommendation B, two studies (4.5%) had a level of evidence 3b and grade of recommendation B, and 15 studies (34,1%) with a level of evidence 4 and grade of recommendation C. First-choice treatments for common warts, such as cryotherapy and salicylic acid, have low-cure rates for plantar warts. Other treatments, such as CPA formulation, immunotherapy, and intralesional bleomycin, which have compassionate use, have higher cure rates. This review should stimulate future high-quality research to evaluate these specialized treatments.

Cellular Proliferation, Dermal Repair, and Microbiological Effectiveness of Ultrasound-Assisted Wound Debridement (UAW) Versus Standard Wound Treatment in Complicated Diabetic Foot Ulcers (DFU): An Open-Label Randomized Controlled Trial.

We aimed to evaluate the effects of ultrasound-assisted wound (UAW) debridement on cellular proliferation and dermal repair in complicated diabetic foot ulcers as compared to diabetic foot ulcers receiving surgical/sharp wound debridement. A randomized controlled trial was performed involving 51 outpatients with complicated diabetic foot ulcers that either received surgical debridement (n = 24) or UAW debridement (n = 27) every week during a six-week treatment period. Compared to patients receiving surgical debridement, patients treated with UAW debridement exhibited significantly improved cellular proliferation, as determined by CD31 staining, Masson's trichrome staining, and actin staining. Bacterial loads were significantly reduced in the UAW debridement group compared to the surgical group (UAW group 4.27 ± 0.37 day 0 to 2.11 ± 0.8 versus surgical group 4.66 ± 1.21 day 0 to 4.39 ± 1.24 day 42; p = 0.01). Time to healing was also significantly lower (p = 0.04) in the UAW group (9.7 ± 3.8 weeks) compared to the surgical group (14.8 ± 12.3 weeks), but both groups had similar rates of patients that were healed after six months of follow-up (23 patients (85.1%) in the UAW group vs. 20 patients (83.3%) in the surgical group; p = 0.856). We propose that UAW debridement could be an effective alternative when surgical debridement is not available or is contraindicated for use on patients with complicated diabetic foot ulcers.

Utility of Blood Parameters to Detect Complications during Long-Term Follow-Up in Patients with Diabetic Foot Osteomyelitis.

The evidence is still unclear regarding the role of blood parameters in detecting complications in patients who suffer from diabetic foot osteomyelitis (DFO). In this study, the aim was to identify the capacity of different blood parameters in the diagnosis and prediction of the onset of complications. A cross-sectional prospective study was carried out with 116 DFO patients. The following blood parameters were evaluated during 1 year of follow-up: leukocytes, neutrophils, lymphocytes, monocytes, eosinophils, basophils, erythrocyte sedimentation rate (ESR), glycemia, glycosylated hemoglobin, C-reactive protein (CRP), alkaline phosphatase, albumin, and creatinine. Complication events were assessed for each participant during the study period. We investigated the association between blood parameter values and the onset of complication events by conducting a receiver operating characteristic curve analysis. Eighty-five (73.3%) patients developed complications. Regarding blood parameters, higher values of lymphocytes and albumin were predictive factors at the 12-month follow-up once the ulcer had healed. Higher values of ESR had predictive and diagnostic value for the onset of complication events, and higher values of CRP and hyperglycemia were diagnostic factors since they were elevated during the occurrence of an event. In conclusion, after suffering from DFO, the elevation of lymphocytes, ESR, CRP, albumin, and glycemia could be useful in detecting and diagnosing patients who are likely to develop a complication. Serial blood tests are a useful tool for early detection by healthcare professionals to prevent complications.

Adipose-Derived Mesenchymal Stem Cells in the Treatment of Diabetic Foot Ulcers: A Review of Preclinical and Clinical Studies.

This review provides an outline of the use of adipose-derived mesenchymal stem cells (AMSCs) in the treatment of diabetic foot ulcers (DFUs). A systematic search of PubMed and the Cochrane database was performed on October 2, 2019. Eighteen studies were identified (14 preclinical and 4 clinical). Studies in animal models have demonstrated that AMSCs enhance diabetic wound healing, accelerate granulation tissue formation, and increase reepithelialization and neovascularization. Only 1 randomized control trial has been published so far. Patients (n = 25) with DFUs were treated using an allogeneic AMSC directly on the wound bed as a primary dressing, and improvements were found in complete wound closure in the treatment group (n = 16). Three clinical studies showed that autologous AMSC might be a safe alternative to achieve therapeutic angiogenesis in patients with diabetes and peripheral arterial disease. Based on the available evidence, AMSCs hold promise in the treatment of DFUs. However, this evidence requires confirmation by well-designed trials. Additional studies are also required to understand some issues regarding this treatment for DFUs. For example, the potential application of autologous or allogeneic AMSCs in different types of DFUs, optimal dose/infusion schedules, safety evaluations, and cost-effectiveness.

Metatarsal Head Resections in Diabetic Foot Patients: A Systematic Review.

A systematic review and proportional meta-analysis were carried out to investigate the complications that occur after surgical metatarsal head resection in diabetic foot patients. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist recommendations were applied, and the selected studies were evaluated using a Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist. PubMed (Medline) and Embase (Elsevier) were searched in December 2019 to find clinical trials, cohort studies, or case series assessing the efficacy of the metatarsal head resection technique in diabetic foot patients. The systematic review covered 21 studies that satisfied the inclusion criteria and included 483 subjects. The outcomes evaluated were the time to heal, recurrence, reulceration, amputation, and other complications. The proportion of recurrence was 7.2% [confidence interval (CI) 4.0-10.4, p < 0.001], that of reulceration was 20.7% (CI 11.6-29.8, p < 0.001), and that of amputation was 7.6% (CI 3.4-11.8, p < 0.001). A heterogeneity test indicated I2 = 72.6% (p < 0.001) for recurrences, I2 = 94% (p < 0.001) for reulcerations, and I2 = 79% (p < 0.001) for amputations. We conclude that metatarsal head resections in diabetic foot patients are correlated with significant complications, especially reulceration.