The evaluation of off-loading using a new removable oRTHOsis in DIABetic foot (ORTHODIAB) randomized controlled trial: study design and rational

Methodological Issues Relevant to Blinding in Physical Medicine and Rehabilitation Research

ABSTRACT

Blinding in research is important, and the field of physical medicine and rehabilitation poses special consideration owing to the patient populations and treatment methodologies used. Historically, blinding has been increasingly relevant to conducting good-quality research. The main reason to blind is to reduce bias. There are several strategies to blinding. At times, when blinding is not possible, alternatives to blinding include sham control and description of study and control groups. Illustrative examples of blinding used in physical medicine and rehabilitation research are described in this article, along with how to assess success and fidelity of blinding.

Comparison of a new versus standard removable offloading device in patients with neuropathic diabetic foot ulcers: a French national, multicentre, open-label randomized, controlled trial

INTRODUCTION

The offloading is crucial to heal neuropathic diabetic foot ulcer (DFU). Removable offloading are the most used devices. Orthèse diabète is a new customized removable knee-high offloading device immobilizing foot and ankle joints, with some specific and innovative features that may improve offloading. We aimed to evaluate the efficiency of this device in DFU healing.

RESEARCH, DESIGN AND METHODS

The evaluation of Offloading using a new removable ORTHOsis in DIABetic foot study is a French multicenter (13 centers) randomized controlled trial with blinded end points evaluation. Adults with neuropathic DFU were randomly assigned to either Orthèse Diabète (experimental device), or any type of conventional (usually used in France) removable offloading devices (control group). The primary outcome was the 3-month proportion of patients with fully healed DFU.

RESULTS

Among 112 randomized patients (men 78%, age 62±10 years), the primary outcome occurred in 19 (33%) participants using conventional device vs 19 (35%) Orthèse Diabète users (p=0.79). Study groups were also comparable in terms of prespecified secondary end points including occurrence of new DFU (25% vs 27% in conventional and experimental groups), ipsilateral lower-limb amputation (4% vs 10%) or infectious complications (14% vs 13%) (p>0.05 for all). Adverse events were comparable between groups, including 4 deaths unrelated to study allocation (1 sudden death, 2 ventricular arrhythmias and 1 pancreatic cancer). Adverse events believed to be related to the device were higher in the Orthèse Diabète group than in the control group (15% vs 4%). Orthèse Diabète was less frequently worn than conventional devices (46% vs 66%, p=0.04).

CONCLUSIONS

Orthèse Diabète, a new removable offloading orthosis immobilizing foot and ankle joints did not show superiority compared with conventional removable devices in neuropathic DFU healing and cannot be recommended to heal DFU.

TRIAL REGISTRATION NUMBER

NCT01956162.

The Superiority of Removable Contact Splints in the Healing of Diabetic Foot during Postoperative Care

OBJECTIVE

Off-loading is one of the crucial components of diabetic foot (DF) therapy. However, there remains a paucity of studies on the most suitable off-loading for DF patients under postoperative care. The aim of our study was to evaluate the effect of different protective off-loading devices on healing and postoperative complications in DF patients following limb preservation surgery.

METHODS

This observational study comprised 127 DF patients. All enrolled patients had undergone foot surgery and were off-loaded empirically as follows: wheelchair+removable contact splint (RCS) (group R: 29.2%), wheelchair only (group W: 48%), and wheelchair+removable prefabricated device (group WP: 22.8%). We compared the primary (e.g., the number of healed patients, healing time, and duration of antibiotic (ATB) therapy) and secondary outcomes (e.g., number of reamputations and number and duration of rehospitalizations) with regard to the operation regions across all study groups.

RESULTS

The lowest number of postoperative complications (number of reamputations: p = 0.028; rehospitalizations: p = 0.0085; and major amputations: p = 0.02) was in group R compared to groups W and WP. There was a strong trend toward a higher percentage of healed patients (78.4% vs. 55.7% and 65.5%; p = 0.068) over a shorter duration (13.7 vs. 16.5 and 20.3 weeks; p = 0.055) in the R group, as well. Furthermore, our subanalysis revealed better primary outcomes in patients operated in the midfoot and better secondary outcomes in patients after forefoot surgery-odds ratios favouring the R group included healing at 2.5 (95% CI, 1.04-6.15; p = 0.037), reamputations at 0.32 (95% CI, 0.12-0.84; p = 0.018), and rehospitalizations at 0.22 (95% CI, 0.08-0.58; p = 0.0013).

CONCLUSIONS

This observational study suggests that removable contact splint combined with a wheelchair is better than a wheelchair with or without removable off-loading device for accelerating wound healing after surgical procedures; it also minimises overall postoperative complications, reducing the number of reamputations by up to 77% and the number of rehospitalizations by up to 66%.

ADIE - Nursing Interventions of Diabetic Foot Ulcer: An Integrative Review of the Literature

BACKGROUND AND AIMS

Diabetic foot ulcer is recognized as a consequence of peripheral neuropathy and peripheral arterial disease amid individuals with diabetes. As is well known, this situation still remains a crucial problem in nursing practice. Available studies describing an algorithm of inter- related nursing interventions concerned with diabetic foot ulcers are limited. Therefore, this integrative review was aimed to present evidence-based practice for overcoming the complications of diabetic foot ulcer as well as preventing lower extremity amputation.

METHODS

This integrative review retrieved scientific literature from PubMed, CINAHL, ProQuest, SAGE Publishing and ScienceDirect databases as published from 2008 to 2017. Thirty-seven studies that met the inclusion criteria were included in this study.

RESULTS

Our findings present that neurologic and circulatory assessments were considered as primary steps prior to conducting interventions. Formulating a diagnosis based upon the assessment results is a principal part to determine appropriate interventions. Multiple experimental studies displayed the effectiveness of certain interventions consist of applying wound cleansing, advanced modern wound dressing, topical therapy, offloading, intensive diabetes education and advanced treatment modalities. Hemoglobin A1c, high-density lipoprotein, procalcitonin, the potential of hydrogen of wound fluid, wound size, neurological and circulatory status were determined as the outcomes measurement which must be correctly evaluated.

CONCLUSION

This review contributes an algorithm for intervening diabetic foot ulcer thereby generating the given name: ADIE (Assessment, Diagnosis, Interventions, and Evaluation). A collaborative care amid multidisciplinary diabetes team is needed for implementing along with evaluating the feasibility of the study findings. Moreover, active family participation also plays a crucial role to achieve successful management of diabetic foot ulcer at home.

New trends in the orthopaedic management of diabetic foot

Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark.Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems.The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs.For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections.In the modern management of the Charcot foot, surgery in the acute phase remains controversial and under investigation. While conventional fixation techniques are frequently insufficient to keep alignment postoperatively, superconstruct techniques could provide a successful fixation.Retrograde intramedullary nailing has been a generally accepted method of achieving stability. The midfoot fusion bolt is a current treatment device that maintains the longitudinal columns of the foot. Also, Achilles tendon lengthening remains a popular method in the management of Charcot foot. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170073.