Reappraising Diabetic Foot Ulcers: A Focus on Mechanisms of Ulceration and Clinical Evaluation

Diabetic foot ulcers (DFU) are one of the most devastating complications of diabetes as they have significant effects on patient morbidity and mortality. Since their first description in the 19th century, our understanding of DFU has evolved as we uncover the mechanisms that mediate ulceration. In this review, we aim to summarize the various pathways that lead to the development of DFU in order to reappraise physicians’ understanding of these complex wounds. Relevant pathways include the following: (1) neuropathy (motor neuropathy, loss of protective sensation, and autonomic sympathetic dysfunction), (2) vascular disease (arterial ischemia, venous insufficiency, and microvascular changes), and (3) metabolism (signaling and immunological effects of hyperglycemia). We also discuss the clinical presentation of DFU and an evidence-based evaluation to assist clinicians in early identification and classification of these wounds to inform management of DFU. Finally, we summarize complications of DFU caused by the various pathways mediating ulceration and briefly overview DFU management in order to educate physicians about the potential risks if left untreated. A better understanding of the synergistic pathways leading to DFU is essential for clinicians to improve DFU diagnosis, tailor intervention, and mitigate significant patient morbidity and mortality.

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Preferred Offloading Modalities for Management of Diabetic Foot Ulcers in Private Clinical Settings: A Survey of Australian Podiatrists

10.21203/rs.3.rs-1157285/v1 ◽

2021 ◽

Author(s):

Adriaan Erasmus ◽

Michael Melek ◽

Malia Ho

Keyword(s):

Diabetic Foot ◽

Online Survey ◽

Management Strategies ◽

Ease Of Use ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Therapeutic Footwear ◽

Human Research Ethics ◽

Protective Sensation ◽

Loss Of Protective Sensation

Abstract Background Diabetic peripheral neuropathy is a common complication of diabetes mellitus. Neuropathy predisposes patients to diabetic foot ulcers (DFU) due to the loss of protective sensation and associated deformities. Management of foot ulcers are multifactorial, but pressure offloading can be considered as one of the most important aspects of management. According to IWGDF Guidelines, non-removable knee-high offloading devices are recommended as the 1st line of treatment for these ulcers. However, this is a very underutilised treatment modality. This study aimed to evaluate the practitioner preferred offloading modalities and reasons for their preference. Methods This project was approved by the university’s human research ethics committee. An online survey was distributed amongst Australian podiatrist via an industry related social media group. The survey collected simple demographical information, management strategies, preferred offloading modalities for the management of diabetic foot ulcers and reasons for their preferred method. Results Sixty-three podiatrists completed the survey with the majority practicing in private clinics. All practitioners treat diabetic foot ulcers regularly with most participants treating up to ten ulcer cases per week and 14% of participants treating more than 20 ulcers per week. Contrary to the IWGDF guidelines, standard therapeutic footwear was the most preferred method of management for the treatment of diabetic foot ulcers, with ease of use reported as the main reason for practitioners using this modality. Non-compliance to the use of non-removable knee-high offloading devices include perceived patient non-compliance and poor tolerance. Conclusion This study shows that practitioners’ offloading strategies do not adhere to the IWGDF guidelines. The reasons for not adhering to the guidelines seems to be a clinical practicality rather than evidence-based practice. Reasons for choosing a management strategy is multi-factorial (not just reducing plantar pressures). Further studies may be required to evaluate the effectiveness of therapeutic footwear in ulcer healing, taking into consideration other factors such as practitioner and patient preference, clinical practicality, and access to support. Based on the findings, this study provides suggestions on how to overcome the barriers that prevent podiatrist from adhering to the recommendations of the IWGDF when selecting offloading devices in general clinical practice.

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Microbial Community Distribution and Core Microbiome in Successive Wound Grades of Individuals with Diabetic Foot Ulcers

Applied and Environmental Microbiology ◽

10.1128/aem.02608-19 ◽

2020 ◽

Vol 86 (6) ◽

Cited By ~ 1

Author(s):

Apoorva Jnana ◽

Vigneshwaran Muthuraman ◽

Vinay Koshy Varghese ◽

Sanjiban Chakrabarty ◽

Thokur Sreepathy Murali ◽

...

Keyword(s):

Community Structure ◽

Microbial Community ◽

Diabetic Foot ◽

Antibiotic Susceptibility ◽

Morbidity And Mortality ◽

Wound Management ◽

Foot Ulcers ◽

High Morbidity ◽

Diabetic Foot Ulcers ◽

Core Microbiome

ABSTRACT Diabetic foot ulcer (DFU) is a major complication of diabetes with high morbidity and mortality rates. The pathogenesis of DFUs is governed by a complex milieu of environmental and host factors. The empirical treatment is initially based on wound severity since culturing and profiling the antibiotic sensitivity of wound-associated microbes is time-consuming. Hence, a thorough and rapid analysis of the microbial landscape is a major requirement toward devising evidence-based interventions. Toward this, 122 wound (100 diabetic and 22 nondiabetic) samples were sampled for their bacterial community structure using both culture-based and next-generation 16S rRNA-based metagenomics approach. Both the approaches showed that the Gram-negative microbes were more abundant in the wound microbiome. The core microbiome consisted of bacterial genera, including Alcaligenes, Pseudomonas, Burkholderia, and Corynebacterium in decreasing order of average relative abundance. Despite the heterogenous nature and extensive sharing of microbes, an inherent community structure was apparent, as revealed by a cluster analysis based on Euclidean distances. Facultative anaerobes (26.5%) were predominant in Wagner grade 5, while strict anaerobes were abundant in Wagner grade 1 (26%). A nonmetric dimensional scaling analysis could not clearly discriminate samples based on HbA1c levels. Sequencing approach revealed the presence of major culturable species even in samples with no bacterial growth in culture-based approach. Our study indicates that (i) the composition of core microbial community varies with wound severity, (ii) polymicrobial species distribution is individual specific, and (iii) antibiotic susceptibility varies with individuals. Our study suggests the need to evolve better-personalized care for better wound management therapies. IMPORTANCE Chronic nonhealing diabetic foot ulcers (DFUs) are a serious complication of diabetes and are further exacerbated by bacterial colonization. The microbial burden in the wound of each individual displays diverse morphological and physiological characteristics with unique patterns of host-pathogen interactions, antibiotic resistance, and virulence. Treatment involves empirical decisions until definitive results on the causative wound pathogens and their antibiotic susceptibility profiles are available. Hence, there is a need for rapid and accurate detection of these polymicrobial communities for effective wound management. Deciphering microbial communities will aid clinicians to tailor their treatment specifically to the microbes prevalent in the DFU at the time of assessment. This may reduce DFUs associated morbidity and mortality while impeding the rise of multidrug-resistant microbes.

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Diabetic foot ulcers: a review of current management

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20174916 ◽

2017 ◽

Vol 5 (11) ◽

pp. 4683 ◽

Cited By ~ 2

Author(s):

Yasmee Khan ◽

Manal M. Khan ◽

M. Raza Farooqui

Keyword(s):

Diabetes Mellitus ◽

Diabetic Foot ◽

Health Condition ◽

Classification Systems ◽

Present Review ◽

Socioeconomic Impact ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Current Management ◽

Patient Morbidity

Diabetic foot ulcers are a serious complication of diabetes mellitus which increases the patient morbidity and also have significant socioeconomic impact. The present review aims to summarize the causes and pathogenesis leading to diabetic foot ulcers, various classification systems and to focus on the current management of this significant and preventable health condition.

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Evaluation of Risk Factors Associated with Diabetic Foot Ulcers in Saudi Arabia

Current Diabetes Reviews ◽

10.2174/1573399814666180816165848 ◽

2019 ◽

Vol 15 (3) ◽

pp. 224-232 ◽

Cited By ~ 2

Author(s):

Mousab Yousef Al-Ayed ◽

Mutasem Ababneh ◽

Asirvatham Alwin Robert ◽

Ahmed Salman ◽

Abdulghani Al Saeed ◽

...

Keyword(s):

Risk Factors ◽

Saudi Arabia ◽

Diabetic Foot ◽

Foot Ulcers ◽

Foot Ulceration ◽

Factors Associated ◽

Vascular Insufficiency ◽

Protective Sensation ◽

Loss Of Protective Sensation ◽

Age Range

<P>Background and Aims: Considering that diabetic foot ulceration is one of the major health issues globally, we aimed to evaluate the risk factors associated with foot ulcers in patients with type 2 diabetes mellitus (T2DM). Methods: A total of 81 T2DM patients (age range: 40-80 years) registered at the Diabetes Treatment Center, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia between April and September 2015 were included in this cross-sectional study after purposive selection and assigning of patient numbers. The selected participants were interviewed and examined, and their medical records were reviewed for sensory, vibratory, and painful neuropathies; vascular insufficiency; retinopathy; and dermatological variations. The Wagner’s classification system was employed to evaluate the stage of patients’ foot ulcers. Results: Among the study participants [mean age range: 56.4 ± 6.72 years; 53 males (65.4%)], cases of loss of protective sensation, foot deformity, amputation history, and dermatological abnormalities were notable. The Wagner gradation value of ulcers were grade 0 for 16% study population, grade 1 for 35.8%, grade 2 for 45.7%, grade 3 for 2.5%, and grades 4 and 5 for 0%. Approximately 19% of the patients had a previous case of amputation and 29.6% had nail disease. The most common footwear reported to be used by the patients was sandals shoes (46%). Conclusion: The issues of loss of protective sensation, vascular insufficiency, deformity, previous amputations, and dermatological abnormalities of the lower limbs were found to be most common among the foot ulceration patients. The study findings thus recommend regular foot examination, following basic hygiene habits, encouragement of the use of appropriate footwear, patient education about foot ulcers, and prompt treatment for minor injuries to prevent further ulceration in DM patients.</P>

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Management of diabetic foot ulcers in a teaching hospital

International Surgery Journal ◽

10.18203/2349-2902.isj20173893 ◽

2017 ◽

Vol 4 (9) ◽

pp. 3088 ◽

Cited By ~ 1

Author(s):

Rajkumar Sade ◽

Dasharadha Jatothu ◽

. Taruni ◽

Kirthana Sade ◽

Nagababu Pyadala

Keyword(s):

Diabetes Mellitus ◽

Diabetic Foot ◽

Previous History ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Morbidity And Mortality ◽

Foot Ulcers ◽

Multi Drug Resistance ◽

Major Public Health Problem ◽

Diabetic Foot Ulcers

Background: Diabetic foot ulcers (DFUs) are major public health problem, especially in developing countries. Still now management of diabetic foot ulcer is the major challenge for surgeons.Methods: A prospective study was done at Kamineni Institute of Medical Sciences, Narketpally; from February 2014 to January 2017. All the collected data was analyzed by the SPSS 20.0 software.Results: A total of 350 DFUs patients was included in this study. Among all of them 77.14% were male and 22.86% were female. Most common age group with DFUs was 40-60 years. All the patients had type 2 diabetes mellitus. The majority of patients were presented foot ulcers between 4 weeks to 32 weeks. 18% patients had previous history of DFUs and 11.14% had previous amputation. The forefoot was commonly affected in 48.3% of cases. Neuropathic ulcers were the most common type of DFUs in 50.6% of cases. Wagner's stage 3, 4 and 5 ulcers were the most common at 20.86%, 28% and 22% respectively. 52.86% patients were treated surgically. Lower limb amputation was the most common surgical procedure performed in 60% of cases. The complication rate was (49.7%) and surgical site infection was the most common complication (34.8%). 60% of cultures had polymicrobial growth and Staphylococcus aureus (53.3%) was the most common microorganism isolated. Most of the microorganisms isolated showed multi drug resistance to commonly used antibiotics except for Carbapenems group drugs (sensitivity 100%). The hospital stay was ranged between 15-116 days. Mortality rate was 9.4%.Conclusions: Diabetic foot ulcer is the major cause of morbidity and mortality among patients with diabetes mellitus. A proper education on foot care and appropriate foot ware, good sugar level control and early surgical intervention is needed to decrease the morbidity and mortality among diabetic foot ulcer patients.

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