Long-term foot outcomes following differential abatement of inflammation and osteoclastogenesis for active Charcot neuroarthropathy in diabetes mellitus

Aims Inflammatory osteolysis is sine-qua-non of active Charcot neuroarthropathy (CN) causing decreased foot bone mineral density (BMD) and fractures. We aimed to explore the effect of anti-inflammatory or anti-resorptive agents for effect on foot bone mineral content (BMC) and consequent long-term outcomes of foot deformities, fractures and amputation. Methods Forty-three patients with active CN (temperature difference >2°C from normal foot) were evaluated. Patients were off-loaded with total contact cast and randomized to receive either methylprednisolone (1gm) (group A), zoledronate (5mg) (group B) or placebo (100ml normal saline) (group C) once monthly infusion for three consecutive months. Change in foot BMC was assessed at 6 months or at remission and followed subsequently up to 4 years for the incidence of new-onset fracture, deformities, or CN recurrence. Results Thirty-six participants (24 male, 12 female) were randomized (11 in group A, 12 group B, 13 group C). The mean age was 57.7± 9.9 years, duration of diabetes 12.3± 5.8 years and symptom duration 6.5± 2.8 weeks. BMC increased by 36% with zoledronate (p = 0.02) but reduced by 13% with methylprednisolone (p = 0.03) and 9% (p = 0.09) with placebo at remission. There were no incident foot fractures, however, two patients sustained ulcers, and 3 had new-onset or worsening deformities and none required amputation during 3.36 ± 0.89 years of follow-up. Conclusion Bisphosphonate for active CN is associated with an increase in foot bone mineral content as compared to decrease with steroids or total contact cast but long-term outcomes of foot deformities, ulceration and amputation are similar. Trial registration ClinicalTrials.gov: NCT03289338.

Is TCC-EZ a Suitable Alternative to Gold Standard Total-Contact Casting?

Background The total-contact cast (TCC) is the gold standard for off-loading diabetic foot ulcers (DFUs) given its nonremovable nature. However, this modality remains underused in clinical settings due to the time and experience required for appropriate application. The TCC-EZ is an alternative off-loading modality marketed as being nonremovable and having faster and easier application. This study aims to investigate the potential of the TCC-EZ to reduce foot plantar pressures. Methods Twelve healthy participants (six males, six females) were fitted with a removable cast walker, TCC, TCC-EZ, and TCC-EZ with accompanying brace removed. These off-loading modalities were tested against a control. Pedar-X technology measured peak plantar pressures in each condition. Statistical analysis of four regions of the foot (rearfoot, midfoot, forefoot, and hallux) was conducted with Friedman and Wilcoxon signed rank tests. Significance was set at P < .05. Results All of the off-loading conditions significantly reduced pressure compared with the control, except the TCC-EZ without the brace in the hallux region. There was no statistically significant difference between TCC-EZ and TCC peak pressure in any foot region. The TCC-EZ without the brace obtained significantly higher peak pressures than with the brace. The removable cast walker produced similar peak pressure reduction in the midfoot and forefoot but significantly higher peak pressures in the rearfoot and hallux. Conclusions The TCC-EZ is a viable alternative to the TCC. However, removal of the TCC-EZ brace results in minimal plantar pressure reduction, which might limit clinical applications of the TCC-EZ.

Der Charcot-Fuß

ZUSAMMENFASSUNGDer Charcot-Fuß ist in Deutschland hauptsächlich mit dem Diabetes mellitus und seiner häufigsten Folgeerkrankung, der Polyneuropathie assoziiert. Diese diabetische neuropathische Osteoarthropathie (DNOAP) weist immer eine Hyposensibilität auf und kann mono- sowie bilateral mit Rötung, Schwellung, Hyperthermie einhergehen. Oft können ein unbemerktes Trauma, eine Operation oder eine Weichteilläsion Auslöser sein. Die Behandlung richtet sich nach der Ausdehnung des Befundes und dem klinischen Stadium – im komplizierten Stadium mit Wunde steht dabei die lokale sowie systemische Ausbreitung der Infektion im Fokus, aber auch eine Entlastung, die Behandlung der Grunderkrankung, die Prüfung des Gefäßstatus und chirurgische Behandlungsmaßnahmen sind essenziell. Die Indikation zu korrigierenden chirurgischen Interventionen wird stringent und zuückhaltend gesehen. Eine optimale orthopädische Schuh- oder TCC (Total Contact Cast)-Versorgung mit entsprechender Anbindung beim Diabetologen und Chirurgen ist neben der optimalen Behandlung der Grunderkrankung entscheidend für die Vermeidung von Komplikationen, die mit einer wesentlich höheren Morbidität und Mortalität assoziiert sind. Kernziel der Behandlung ist die Prävention von Rezidiven. Die DNOAP muss vor diesem Hintergrund als interdisziplinäres Krankheitsbild verstanden werden

The Custom Total Contact Cast to Offload Foot Ulcers in the Presence of Biomechanical Deformities: A Case Report

BACKGROUND: Although offloading foot ulcers with a total contact cast (TCC) remains the cornerstone of managing these wounds, the TCC is underutilized. Patient intolerance and potential iatrogenic complications due to TCCs’ general lack of customizability and the inability to address flexible biomechanical deformities that are not in the sagittal plane may be one of the reasons patients with foot ulcers do not receive this crucial component of care. PURPOSE: To describe the use of a novel approach to the standard TCC technique that uses strategic padding to potentially increase patient compliance and comfort while decreasing the likelihood of iatrogenic ulceration, as well as to correct flexible frontal plane biomechanical deformities with casting tape that is pulled medial to lateral, or lateral to medial, to bring the plantar surface of the foot to neutral position. METHODS: The custom total contact cast (C-TCC) was used in a 54-year-old woman who had diabetes, obesity, and a flexible cavovarus foot type with a recurring plantar fifth metatarsal base wound. Weekly debridement followed by silver dressings and C-TCC application were performed. The latter included strategic padding, 2 forms of plaster of paris with contouring, fiberglass, and medial-to-lateral positioning of the foot during application. RESULTS: This case study describes two (2) treatment episodes, with a focus on the second episode. At initial presentation, the ulcer took 5 weeks to heal. During the second treatment, a 48.7% reduction in wound volume was noted after 1 week. By the fourth week of treatment, a 98.7% wound volume reduction was achieved. By the ninth week, the ulcer epithelialized completely. At 1-month and 12-month follow-ups, the site remained fully epithelialized. No iatrogenic ulcerations, cast discomfort, or ambulatory dysfunction were reported by the patient. CONCLUSION: In this case, the C-TCC helped address flexible frontal plane deformities and facilitated healing. Randomized, controlled clinical studies to evaluate the safety and effectiveness of different TCC methods are needed to guide care and improve the utilization of optimal offloading methods for the management of plantar foot ulcers.

Differential Abatement of Inflammation And Osteoclastogenesis In Active Charcot Neuroarthropathy: Mechanistic Insights From Randomized Controlled Study

AimsInflammatory osteolysis is the sine-qua-non of active Charcot neuroarthropathy (CN). This study is aimed to provide mechanistic insights into pathogenesis of CN by exploring the role of methylprednisolone or zoledronate for remission of active CN. MethodsThirty-six patients with active CN (temperature difference >2°C from normal foot) were evaluated for time to remission. Patients were off-loaded with total contact cast and randomised to receive either methylprednisolone (1gm), zoledronate (5mg) or placebo (100ml normal saline) once monthly infusion for three consecutive months. Change in inflammatory cytokines (TNF-α, IL-1β), bone turnover markers (P1NPand CTX) and bone mineral content (BMC) was assessed. ResultsTime to remission of active CN was 19.4 ± 2.8 weeks with methylprednisolone compared to14.6 ± 4.4 and 13.5 ± 2.9 weeks (p<0.05) with zoledronate and placebo, respectively. TNF-α levels reduced by 27% (p=0.03) with methylprednisolone,18% with zoledronate and 16% with placebo (p>0.05), while IL-1β reduced by 30% (p=0.02) with methylprednisolone, 21% with zoledronate and 16% with placebo (p>0.05). P1NP decreased by 5%, 24% and 19% with methylprednisolone, zoledronate and placebo, respectively. CTX decreased by 35% and 11% with zoledronate and placebo respectively but increased with methylprednisolone (18%) (p>0.05). Conclusion Effective suppression of either inflammation with methylprednisolone or osteoclastogenesis with zoledronate do not translate into earlier remission of active CN. The role of non-cytokine and non-inflammatory pathways for the activation of osteoclastogenesis in CN is purported.

O processo de cicatrização de úlceras plantares associadas à terapia de contato total: uma revisão integrativa

Introdução: Mapear a produção científica nacional e internacional relacionada a cicatrização de úlcera plantar com a utilização de terapia de contato total; e discutir as contribuições da produção científica captada para a qualidade do cuidado em Enfermagem em Podiatria Clínica. Materiais e Métodos: Revisão integrativa, que utilizou como bases de dados a Biblioteca Virtual em Saúde e PubMed. O recorte temporal deu-se entre 2012 a 2017. Resultados: Todos as produções captadas foram de periódicos internacionais, com uma incidência maior no ano de 2014, emergindo três categorias: eficácia da terapia de contato total não removível; tipos de terapia de contato total e suas comparações e contribuições para a qualidade do cuidado em enfermagem em Podiatria Clínica. Considerações finais: Propõe-se a realização de novos estudos. Fica notória a necessidade da terapia de alívio da pressão plantar para o manejo e cura da lesão, sendo o mais indicado o instant total contact cast, devido ser eficaz e ter menor chance de danos.

The Real-Life Outcome of VACOped Boot in the Management of Diabetic Foot Ulcers

The total contact cast (TCC) is considered the gold standard treatment to off-load diabetic foot ulcers (DFUs); however, the use of TCC can be limited due to various reasons such as underlying infections, ischemia, and patient’s reluctance. Removable cast walkers are used in such cases, and the VACOped boot is one such device. The aim of this study was to analyze the results of the VACOped boot in the treatment of DFUs in real life. Case records of all patients with DFUs treated with a VACOped from 2011 to 2017 were reviewed retrospectively. Eighty-three episodes of ulcerations in 42 subjects were identified, of which 48 (57.8%) healed in a median duration of 17.5 (95% confidence interval = 15-33) weeks with the use of the VACOped and 35 (42.2%) discontinued its use. The median duration of healing with the VACOped of 17.5 weeks appears to be longer, but this cohort included patients with underlying infection and ischemia, which are often excluded in the clinical trials of off-loading. Our data show that the VACOped application is preferred by many patients and seems to be equally effective to other removable cast walkers.

A Biomechanical Examination of Prefabricated Total Contact Cast Kits: Relevance to Patients With Diabetic Neuropathy

The traditional Total Contact Cast (TCC) is considered the gold standard for treating plantar diabetic ulcers. A number of prefabricated TCC kits have been introduced, which offer a user-friendly casting process for health care providers. Our objective was to evaluate pressure reduction and gait characteristics after application of a TCC kit (TCC-EZ) and traditional TCC. Fifteen individuals (9 males, 6 females; median age of 51.5 years [range = 40.5-71.2 years]) completed 30-m walking trials while fitted with TCC-EZ and TCC in a randomized order. A pair of automated wireless photogate sensors captured time to traverse the distance and pedobarographic insoles measured and recorded plantar pressures. Paired t tests were used to compare peak pressure, gait speed, and cast weights across the 2 modalities. Peak pressure and cast weight were significantly lower in the TCC-EZ arm (169.6 ± 41.3 kPa vs 214.9 ± 63.2 kPa, P = .0048; and 1.79 ± 0.17 kg vs 2.11 ± 0.25 kg, P = .0004). Contact area and gait speed were not significantly different between the 2 modalities (140.4 ± 25.8 cm2 vs 126.9 ± 37.8 cm2, P = .0228, Cohen’s d = 0.40; and 0.94 ± 0.19 m/s vs 0.83 ± 0.26 m/s, P = .0532, Cohen’s d = .48). TCC-EZ was found to provide more favorable pressure distributions compared with TCC. TCC-EZ is also lighter and may be a preferred treatment modality for patients. More research is necessary to reveal the clinical effectiveness of prefabricated total contact kits.