Offloading for the Diabetic Foot: Considerations and Implications

Standardized Wound Care: Patchwork Practices?

Standardized care is crucial in health care for ensuring consistent, safe, high-quality, efficient, and evidence-based practices. Care pathways that standardize procedures promote adherence to best practices, reduce variability in treatment, and encourage collaboration among health care teams. This approach ultimately improves patient outcomes, enhances safety, and boosts the overall effectiveness of health care services. However, despite these benefits being widespread across most of the U.S. health care system, wound care stands out as an area where standards can vary significantly. The inconsistency in wound care standards in the United States can be traced to several factors. These include limited structured clinical wound care education, the discretion of health care providers in different business environments, differences in wound care settings, varying access to advanced treatments and technology, patient demographics and socioeconomic status, as well as differences in state laws and regional or institutional practices. Addressing these disparities requires a comprehensive approach that considers the complex interplay of the abovementioned factors. Active measures are needed to improve access, equity, and the quality of wound care services for all patients, regardless of where they live, their socioeconomic status, their health care coverage, or the business interests of providers and their institutions as well as of vendors marketing wound care products inconsistent with evidence-based practice. By understanding and actively addressing these factors, we can work toward achieving more standardized, evidence-based, and patient-centered practices in wound care across the nation.

A mouldable fibreglass backslab device as a novel approach to offload chronic plantar foot ulcers: A retrospective observational audit

BACKGROUND

Pressure offloading is a critical component of plantar foot ulcer management, including diabetes-related foot ulcers (DFU). Conventional offloading options such as total contact casting and removable knee-high walkers may be unsuitable or unsuccessful in patients with morbid obesity, intermittent lower limb oedema, high exudative wounds or poor mobility. A mouldable fibreglass backslab device (BSD) may be a practical alternative to be considered in these situations.

METHODS

Data were retrospectively collected on 28 patients (29 foot ulcers) with non-healing ulcers who received a BSD to offload their foot ulcer as an extension to standard offloading care. Baseline data included: patient demographics, type of offloading prior to BSD application, date of ulcer onset, days ulcer present prior to BSD application and ulcer size at BSD initiation. Measures of success included ulcer size reduction 12 weeks post-BSD application, time to complete ulcer healing in BSD, time to 50% reduction in ulcer size post-BSD application and total number of days ulcer present.

RESULTS

The median (IQR) ulcer area and ulcer duration at baseline for 19 patients (20 ulcers) who used the BSD was 1.65 (0.4-3.8) cm2 and 531 (101-635) days. At 12 weeks, the median (IQR) ulcer area was 0.3 (0-0.55) cm2 with a median (IQR) reduction of 97 (80-100) %. Nine (45%) ulcers achieved complete wound healing (100% reduction in wound size) at 12 weeks post-BSD application, and the remaining 11 (55%) ulcers achieved at least 50% reduction in wound size. The median (IQR) time to complete wound healing and 50% reduction in wound size was 71 (35-134) days and 24 (15-44) days, respectively. Nine patients ceased use of the BSD and reverted to conventional offloading before their wounds had healed. Of these, four patients achieved a 50% reduction in wound size at the 12-week mark with conventional offloading.

CONCLUSION

Our preliminary data suggests that a mouldable fibreglass BSD may be a practical offloading option in the management of DFUs, especially when conventional offloading methods are unsuccessful, unsuitable or unacceptable to patients. Higher level evidence is required to demonstrate suitability or efficacy of the BSD compared to current evidence-based recommended offloading methods.

Management of Diabetic Foot Ulcers with Two Forefoot Offloading Techniques: Case Series

ABSTRACT

Offloading is a key principle to healing diabetic foot ulcers. Nonremovable knee-high offloading devices are considered the criterion standard for offloading plantar forefoot ulcers. However, patients exhibit a limited tolerance for these devices, which contributes to a lack of use. In this case series describing two patients, the authors share two alternative offloading modalities for the treatment of diabetic plantar forefoot ulcers. One patient was managed using a football offloading dressing, and the other was managed with a modified felted football dressing. The football and modified felted football offloading dressings provide a cost-effective, less time-consuming application and often are a better-tolerated alternative to nonremovable knee-high offloading devices. Clinical findings support further investigation into dressing options tolerated by patients with improved adherence and optimal healing outcomes.

Offloading systems for the treatment of neuropathic foot ulcers in patients with diabetes mellitus: a meta-analysis of randomized controlled trials for the development of the Italian guidelines for the treatment of diabetic foot syndrome

AIM

To compare the effectiveness of commonly used offloading devices for the treatment of neuropathic foot ulcers in patients with diabetes mellitus. This meta-analysis (MA) has been performed for giving an answer to clinical questions on this topic of the Italian guideline on diabetic foot syndrome.

METHODS

The present MA includes randomized controlled studies (duration > 12 weeks) comparing, in patients with diabetes mellitus and non-infected neuropathic foot ulcer: any offloading device vs either no offloading device or conventional footwear; removable versus non-removable offloading devices; surgical procedure vs other offloading approaches. The primary endpoint was ulcer healing.

RESULTS

A total of 184 studies were identified, and 18 were considered eligible for the analysis. We found that: any plantar off-loading, when compared to the absence of plantar offloading device, is associated with a higher ulcer healing (MH-OR: 3.13 [1.08, 9.11], p = 0.04, I2 = 0%); total contact cast or nonremovable knee-high walker, compared to other offloading devices, had a higher ulcer healing rate (MH-OR: 2.64 [1.43, 4.89], p = 0.002, I2 = 51%); surgical offloading for active ulcers in combination with post-surgery offloading achieves higher ulcer healing rate when compared to offloading devices alone (MH-OR: 6.77 [1.64, 27.93], p = 0.008, I2 = 0%).

CONCLUSIONS

Any plantar offloading, compared to the absence of plantar offloading device, is associated with a higher ulcer healing rate. Total contact cast or nonremovable knee-high walker, compared to other offloading devices, is preferable. Surgical offloading for active ulcers, in combination with post-surgery offloading devices, achieves a higher ulcer healing rate when compared to other offloading devices alone. Further studies with a larger cohort of patients with diabetic neuropathic foot ulcers and extended follow-up periods are necessary.

The Role of Leukocyte-Platelet-Rich Fibrin in Promoting Wound Healing in Diabetic Foot Ulcers

To explore the effect of leukocyte-platelet-rich fibrin (L-PRF) on promoting wound healing in diabetic foot ulcers. A total of 42 patients with diabetic foot ulcers at our hospital from January 2017 to July 2020 were retrospectively analyzed. A control group and a PRF group were established. The two groups of patients underwent debridement. In the platelet-rich fibrin (PRF) group, autologous L-PRF was used to cover ulcer wounds. One time each week, Vaseline gauze was used to cover the ulcer wounds. In contrast, the control group was treated with the external application of mupirocin ointment and recombinant human epidermal growth factor gel (yeast). Two times each week, the sterile Vaseline gauze was covered with a bandage. Both groups were treated for 5 weeks. The wound recovery of the two groups was observed. During the early stage of treatment (first and second weeks) for diabetic foot ulcers, the wound healing rate was significantly better with L-PRF treatment than traditional treatment. For later-stage treatment (third to fifth weeks), the overall cure rate was higher with L-PRF than the traditional treatment method. L-PRF can effectively promote wound healing in diabetic foot ulcers.

Using a contralateral shoe lift to reduce gait deterioration during an offloading fast-walk setting in diabetic peripheral neuropathy: A comparative feasibility study

AIMS

Diabetic peripheral neuropathy (DPN) is a predictor of foot ulcers and leads to sedentary behaviour. This comparative study evaluated gait and feasibility of a 20-minute fast walk, at 40-60% of cardiopulmonary capacity, in individuals with DPN wearing an offloading boot and a contralateral shoe balancer.

METHODS

Gait parameters were measured with inertial sensors on 32 individuals (group with DPN [n = 16], group with diabetes but without DPN [n = 9], and a group without diabetes/DPN [n = 7]). Feasibility was assessed by feedback on perceived effort and adverse events. Gait outcomes were compared between groups with or without a shoe balancer using one-way ANOVAs.

RESULTS

The three groups were equivalent in terms of activity level and age and gender except for the body mass index. Both groups with diabetes exhibited minimal decreased gait speed (p > 0.005) and the DPN group exhibited increased double-support percentage (+4.6%, p = 0.01) while walking with an offloading boot and contralateral shoe balancer. The use of a contralateral shoe balancer reduced gait asymmetry. Lower physical activity level was associated with further gait deterioration in all groups. Few adverse events were reported, and 91% of participants reported that the proposed activity would be feasible daily.

CONCLUSIONS

The offloading boot deteriorated gait function, but a contralateral shoe balancer minimized its impact, especially in the context of physical activity in people with diabetes and DPN.

Physiotherapeutic interventions in the treatment of patients with diabetic foot ulcers: a systematic literature review

BACKGROUND

Diabetic foot ulcers are chronic wounds that are difficult to heal, with a high rate of recurrent hospitalizations. Due to its multifactorial complexity, treatment must be considered as multidisciplinary, with adjuvant therapy required to aid the healing process.

OBJECTIVES

To identify physiotherapeutic interventions for the treatment of diabetic foot ulcers through a systematic literature review.

DATA SOURCES

PubMed, Cochrane Library, SciELO and Web of Science were searched in April 2020.

STUDY SELECTION OR ELIGIBILITY CRITERIA

The inclusion criteria for this review were: randomised controlled trial published in the last 5 years; written in Portuguese, English or Spanish; subjects aged> 18 years with a diagnosis of diabetic foot ulcers; and physiotherapeutic intervention in combination with multidisciplinary wound management. The methodological quality was assessed using the PEDro scale.

RESULTS

Eight studies were included. Physiotherapists can treat diabetic foot ulcers using therapeutic exercises, electrotherapy, manual therapy and assistive technologies. All physiotherapeutic interventions were adjuvant to standard treatment for wounds provided by other health professionals. The main outcomes were wound size and healing time, with highly favourable results obtained for the experimental groups compared with the control groups.

CONCLUSIONS

Therapeutic exercise, electrotherapy, manual therapy and assistive technologies are physiotherapeutic modalities that, when combined with standard treatment, have been shown to be beneficial in the healing of diabetic foot ulcers.

Comparing a non-removable total contact cast with a non-removable softcast in diabetic foot ulcers: A retrospective study of a prospective database

OBJECTIVE

Diabetic foot ulcers (DFUs) are mostly cured by an off-loading cast. Healing ratios of a non-removable Total Contact Softcast (TCS) were compared to a conventional Total Contact Cast (TCC), the latter reporting negative effects on lifestyle and transportation.

METHODS

Analysis of prospectively collected data for 2010-2017. Included were patients with a neuropathic DFU. Ischemic ulcers were excluded, as were Charcot arthropathy, non-plantar/non-forefoot ulcer location, and compliance issues. Patients with TCS were compared to TCC. Primary and secondary outcomes were healing ratio and healing time of DFU.

RESULTS

50 patients with 61 cast periods were included. Mean age was 63.7 ± 10.1 years. Overall successful ulcer healing was 71% (43/61). Except for depth of the DFUs, between-group patient characteristics were comparable; deeper DFUs were reported in the TCC group. This group reported 65% healed DFU (22/34), the TCS group 74% (20/27). Mean healing time was 8.4 weeks (95 %CI 5.9-10.8) for TCC and 5.5 weeks (95 %CI 4.2-6.9) for TCS (p = 0.052). Depth of the wound was a confounder.

CONCLUSIONS

TCS had a similar DFU healing ratio and a potentially clinically relevant effect (HR 1.47, 95 %CI 0.64-3.38) on healing time (ns). Ulcer depth is important for time to ulcer healing. A randomized study is recommended.

Magnetic Resonance Imaging Data Features to Evaluate the Efficacy of Compound Skin Graft for Diabetic Foot

This study aimed to analyze the role of magnetic resonance imaging (MRI) data characteristics based on the deep learning algorithm in evaluating the treatment of diabetic foot (DF) with composite skin graft. In this study, 78 patients with DF were randomly rolled into the experimental group (composite skin graft) and control group (autologous skin graft) with 39 patients in each group. MRI scans were performed before and after treatment to compare the changes of experimental observation indicators such as healing time, recurrence rate, and scar score. The results showed that T1-weighted imaging (T1WI) of the scanning sequence was considerably increased in the experimental group after treatment. The signal intensity of fat-suppressed T2-weighted imaging (T2WI) and fat-suppressed T1WI enhancement sequences was considerably decreased (P < 0.05). In addition, compared with the control group, the recurrence rate, healing time, and scar score in the experimental group were considerably decreased (P < 0.05). The accuracy, specificity, and sensitivity of MRI imaging information in evaluating the therapeutic effect of DF patients were 85.2%, 89.75%, and 86.47%, respectively. According to the specificity and sensitivity, the subject operating characteristic curve was drawn, and the area under the curve was determined to be 0.838. In summary, MRI image data characteristics based on the deep learning algorithm can provide auxiliary reference information for the efficacy evaluation of compound skin transplantation for DF.

Offloading treatment in people with diabetic foot disease: A systematic scoping review on adherence to foot offloading

BACKGROUND AND AIMS

To identify measurement methods, proportions of adherent participants, factors affecting adherence, and concordance promoting interventions.

METHODS

A systematic scoping review was conducted by searching Medline, CINAHL, PubMed, EMBASE, and EMCARE databases.

RESULTS

Twenty-four trials were identified from 1001 citations. Only 25% of the included studies used objective methods to quantify adherence. The proportion of adherent participants (≥80% of daily steps/time) ranged from 28% to 60%. Psychosocial factors are the most common influencers of adherence. However, interventions for improving compliance are lacking.

CONCLUSION

There is a need to accurately quantify and optimize adherence to foot offloading in people with diabetes.