Gait-related strategies for the prevention of plantar ulcer development in the high risk foot

High plantar pressures lead to ulceration in the diabetic foot, particularly in the forefoot region around the metatarsal heads. High plantar pressures persist during gait due to factors such as peripheral neuropathy, foot deformities, limited ankle dorsi flexion range of motion and reduced plantar tissue thickness. Strategies impinging upon gait such as the use of appropriate therapeutic footwear, custom-moulded insoles and injectable silicone can help to reduce plantar pressures and attenuate the risk for ulceration. Shoes adapted with external rocker profiles facilitate plantar flexion and restrict sagittal plane motion of the metatarsophalangeal joint, reducing pressures in the region of the metatarsal heads. Insoles custom-moulded to patient's feet help to reduce plantar pressures and minimise the risk of ulceration in the forefoot region. The loss of subcutaneous fat tissue in the diabetic foot enhances bony prominences and predisposes the foot to high-pressure areas. Silicone is a biocompatible material that can be safely injected into plantar soft tissue to augment tissue thickness and prevent the development of ulceration. This enhancement to the subcutaneous layer is remarkably well retained and is a generally well-adopted procedure in the clinical setting.     

Determinants of plantar pressures in the diabetic foot

The aim of this study was to determine, by the use of regression analysis, the factors that are associated with the increased plantar pressure in the diabetic foot. In-shoe plantar pressure measurements using the Novel Pedar were carried out on 50 subjects with diabetes. Variables measured were age, body weight, duration of diabetes, a number of selected structural radiographic angles, soft tissue thickness, plantarflexion, and dorsiflexion strength at the ankle and first metatarsophalangeal joint, Neuropathy Symptom Score, and the Michigan Neuropathy Disability Score. Stepwise regression modelling indicates that 28% of the variability in hallux peak pressure could be explained by the first metatarsophalangeal joint range of motion and the Michigan Neuropathy Disability Score (P=.0004). The Michigan Neuropathy Disability Score explained 17% of the peak pressure under the first metatarsal head (P=.002). None of the measured variables could explain any of the variation in peak pressure plantar to the lateral forefoot. Thirty-two percent (32%) of the variability in peak pressure under the heel was explained by the Michigan Neuropathy Disability Score and age (P<.0001). Very little of the variation in the pressure time integrals could be explained by the measured variables except for 10.3% of the variation in the pressure time integral for the heel being explained by body weight. This study has shown that neuropathy-related variables play an important role in the plantar pressure under the diabetic foot. The range of motion of the first metatarsophalangeal joint is also important in determining pressures under the hallux.     

Downloading plantar foot pressures in the diabetic patient

Pressure downloading (offloading) is the most important component in the prevention and treatment of diabetic foot ulcers because peripheral neuropathy is a major contributing factor to more than 90% of all diabetic foot ulcers. Downloading techniques range from the simplest insole, through many types of orthotics and footwear modifications including the ankle-foot orthosis and total contact casting, to surgical procedures. A philosophical difference exists between surgical and nonsurgical approaches, with the patient subjected to the bias of the practitioner. This article explores uniting both surgical and nonsurgical pressure downloading techniques, using a modified Carville Classification System to help the practitioner determine the appropriate method(s) of downloading. By adding a Category 4 to include diabetic persons with foot ulcers or acute Charcot events, a seamless system is obtained to categorize and treat all people with diabetes with pressure downloading recommendations.     

颈动脉内膜中层厚度对糖尿病足溃疡创面的影响

目的探讨颈动脉内膜中层厚度(IMT)对糖尿病足溃疡创面的影响。方法选取糖尿病足患者181例,未合并糖尿病足2型糖尿病患者62例(非糖尿病足组)为研究对象,测定IMT值,糖尿病足溃疡患者按IMT值分三组:颈动脉内膜厚度正常组(IMT<0.9 mm),颈动脉内膜增厚组(IMT≥0.9 mm)及颈动脉斑块组,回顾性分析患者空腹血糖(FBG)、糖化血红蛋白(HbA1c)、血压、低密度脂蛋白胆固醇(LDL-C)、肌酐(Cr)、踝肱指数(ABI)、糖尿病足Wagner分级等资料。结果颈动脉内膜厚度正常组、颈动脉内膜增厚组、颈动脉斑块组糖尿病足Wagner分级依次升高,差异有统计学意义(P<0.05);随着IMT升高,患者的FBG、HbA1c、LDL-C、Cr、ABI、血压等水平均逐渐增高,差异有统计学意义(P<0.05或P<0.01);相关性分析显示IMT值与FBG、HbA1c、LDL-C、Cr、ABI、收缩压呈正相关(r分别为0.183、0.149、0.304、0.421、0.840、0.161,P均<0.05);多元回归分析显示HbA1c、收缩压、ABI为血管内膜增厚的危险因素。结论颈动脉IMT值与糖尿病足创面严重程度密切相关,IMT值越高,糖尿病足创面情况越严重,IMT值可能可作为糖尿病足创面严重程度及预后的判断指标之一。     

Management of a diabetic foot ulcer

A chronic diabetic foot ulcer requires a search for the etiology. The three main causes to search for are poor off-loading compliance, osteomyelitis, and peripheral vascular disease. The level of severity is measured with the U.T. classification and the level of infection with the classification of the International Consensus on the Diabetic Foot. Peripheral vascular disease must be precisely evaluated by Doppler ultrasound, which describes all the arteries of the lower limb. Angiography is required only in case of revascularization. Treatment of the ulcer includes strict off-loading, topical treatment, optimal treatment of hyperglycemia, and antibiotic therapy on a case-by-case basis for osteomyelitis and/or, angioplasty or by-pass procedures. Osteomyelitis can be treated by associating conservative surgery, antibiotic therapy, and off-loading. No amputation, even of one toe, must be done without a previous vascular check-up. Off-loading of the ulcer must be regularly checked. Poor off-loading compliance must be systematically investigated if the ulcer worsens or healing is delayed.     

超声清创术对糖尿病足溃疡创面细菌清除及微循环作用的临床研究

目的 评价超声清创术对糖尿病足溃疡创面细菌的清除作用及对微循环的影响,探讨其可能的促愈机制.方法 采用随机对照法将2008年5月至2009年2月住院的糖尿病足患者24例分为标准治疗+普通冲洗组(ST组)和标准治疗+超声清创组(SU组)各12例,分别对两组治疗20d内溃疡愈合速度、创面微循环改变及创面细菌清除作用进行比较.结果 (1)SU组第20天平均创面愈合速率[(0.87±0.11)%]显著快于ST组[(0.65±0.14)%](P<0.05).(2)SU组治疗后创面平均血流灌注量[(0.91±0.18)PU]及经皮氧分压[(34.66±6.08)mmHg]显著高于ST组[(0.80±0.19)PU和(32.83±6.97)mmHg](P均<0.05).(3)SU组治疗后创面细菌量显著少于ST组(P<0.05).结论 超声清创术可通过减轻伤口细菌负荷及促进创面微循环,而促进糖尿病足的伤口愈合.     

表皮生长因子治疗糖尿病足溃疡的研究进展

糖尿病足是糖尿病常见的慢性并发症之一,15%的糖尿病患者可能发生足部溃疡。溃疡创面局部生长因子及受体活性下降和数量的绝对或相对缺乏是其难以愈合的病理生理基础。表皮生长因子(EGF)通过促进细胞迁移、增殖及细胞外基质合成等参与溃疡创面愈合。外源性EGF作为一种新的治疗手段,局部应用于糖尿病足溃疡取得显著效果。通过组织工程学技术,EGF释药方式不断改善,并可与其他生长因子联合应用,具有广泛前景。     

Diabetic foot ulcer incidence in relation to plantar pressure magnitude and measurement location

AimsWe prospectively examined the relationship between site-specific peak plantar pressure (PPP) and ulcer risk. Researchers have previously reported associations between diabetic foot ulcer and elevated plantar foot pressure, but the effect of location-specific pressures has not been studied.MethodsDiabetic subjects (n = 591) were enrolled from a single VA hospital. Five measurements of in-shoe plantar pressure were collected using F-Scan. Pressures were measured at 8 areas: heel, lateral midfoot, medial midfoot, first metatarsal, second through fourth metatarsal, fifth metatarsal, hallux, and other toes. The relationship between incident plantar foot ulcer and PPP or pressure–time integral (PTI) was assessed using Cox regression.ResultsDuring follow-up (2.4 years), 47 subjects developed plantar ulcers (10 heel, 12 metatarsal, 19 hallux, 6 other). Overall mean PPP was higher for ulcer subjects (219 vs. 194 kPa), but the relationship differed by site (the metatarsals with ulcers had higher pressure, while the opposite was true for the hallux and heel). A statistical analysis was not performed on the means, but hazard ratios from a Cox survival analysis were nonsignificant for PPP across all sites and when adjusted for location. However, when the metatarsals were considered separately, higher baseline PPP was significantly associated with greater ulcer risk; at other sites, this relationship was nonsignificant. Hazard ratios for all PTI data were nonsignificant.ConclusionsLocation must be considered when assessing the relationship between PPP and plantar ulceration.     

老年糖尿病患者足病变的诊断与防治

糖尿病足的定义是发生于糖尿病患者的与局部神经异常和下肢远端外周血管病变相关的足部感染、溃疡和／或深层组织破坏。国外的资料说明，所有的因糖尿病有关问题的住院中，糖尿病足占到47％。糖尿病足溃疡和截肢所带来的医疗耗费巨大，在美国此项费用几乎相当于其余糖尿病并发症的医疗花费的总和。     

糖尿病周围神经病变与足型及足底压力的关系

目的分析糖尿病周围神经病变与糖尿病患者足型及静态足底压力的关系。方法2007年8月20日至2008年10月14日从华西医院内分泌科门诊及住院患者中整群抽取540例糖尿病患者（糖尿病组）,其中男227例,女313例,平均年龄（59±12）岁,体质指数（24±4）kg／m^2;另从成都市武侯区纳入年龄、性别、体质指数匹配的健康者231名（健康对照组）,其中男84名,女147名,平均年龄（64±11）岁,体质指数（23±4）kg／m^2。由专人使用密西根神经病变筛查量表（MNSI量表）对糖尿病组患者进行周围神经病变评估。使用足底图像扫描仪及足底压力测量仪测定研究对象足型、足底各部位静态相对压力峰值。采用t检验或卡方检验进行数据统计。结果2组参试者足底静态平均压力峰值（36±21VS36±22,t=-0．544,P=0．587）及足底各部位静态压力峰值无明显差异。糖尿病患者据MNSI评分分成A组（MNSI评分0～4分）、B组（MNSI评分4．5—6．5分）、C组（MNSI评分7分以上）,3组人群体质量及体质指数与健康对照组无差异。3组人群静态足底平均压力峰值与健康对照组比较无明显差异（A组为36±20,B组为35±20,C组为35±20,健康对照组为36±22）。各组足底各部位静态相对压力峰值与健康对照组比较差异亦无统计学意义（均P〉0．05）。糖尿病组锤状趾的发生率明显高于健康对照组[8．7％（47／540）VS4．3％（10／231）,X^2=3．966,P=0．029]。糖尿病组锤状趾和扁平足患者MNSI评分[（6．2±2．0）分VS（5．4±1．2）分,t=2．145,P=0．032;（6．6±2．1）分VS（5．4±1．2）分,t=2．339,P=0．02]高于糖尿病患者。结论MNSI评分不能预测糖尿病患者足底静态压力的变化;糖尿病周围神经病变是足部畸形发生的危险因素;伴足底压力升高或足部畸形的糖尿病周围神经病变患者是糖尿病足的高危人群。     

The effect of nonweight-bearing exercise and protocol adherence on diabetic foot ulcer healing: a pilot study

I?nnovative approaches to the prevention and treatment of foot wounds in persons with diabetes mellitus are needed and preliminary research suggests that exercise therapy may increase joint mobility and blood flow. A 12-week, prospective, quasi-experimental pilot study was conducted to evaluate the potential influence of nonweight-bearing ankle exercises, and adherence to same, on the size of neuropathic, diabetic foot wounds in community-dwelling older adults. Nineteen patients were recruited. Of those, 10 (88.9% men) were randomized to ankle exercise treatments and nine (50% men) continued their previous care regimen. Patients randomized to the exercise program were younger and had smaller wounds than those in the control group (average age 62.2 ± 8.54 versus 74.25 ± 16.25 years and measurement 0.94 cm2 ± 1.89 versus 2.53 cm2 ± 3.647, respectively). Thirty percent (30%) of the patients in the exercise and 33.3% in the control group healed. The percent wound reduction between groups was not significantly different (Mann Whitney U test, P = .696). Adherence to the recommended exercise program was variable but 70% performed some exercises. The results of this pilot study provide important lessons for future studies, including the need to enroll more patients and provide more exercise guidance. Considering the increasing prevalence of diabetes mellitus and resultant complications, as well as the potential benefits of this non-invasive treatment regimen, larger studies are warranted.     

山莨菪碱软膏在糖尿病足溃疡治疗中的应用

糖尿病足溃疡的治疗棘手。本研究在控制血糖、抗菌、清创等综合治疗的基础上 ,加用局部外涂山莨菪碱软膏的方法 ,效果良好。一、资料和方法1.临床资料 :共 2 1例 (男 9,女 12 )。按ＷＨＯ(1985 )标准均诊断为 2型糖尿病。门诊治疗 10例 ,住院 3天～ 2 0天后转为家庭治疗 10例 ,远程通讯指导治疗 1例。年龄 5 3～70岁 ,平均 6 1.1岁。糖尿病病程 5～ 18年 ,平均 8.4年。 1例合并酮症酸中毒患者随机血糖 2 3.7ｍｍｏｌ/Ｌ ,19例空腹血糖 (ＦＢＧ) 7.2～ 15 .6ｍｍｏｌ/Ｌ ,平均 13.4ｍｍｏｌ/Ｌ。ＨｂＡ1ｃ7.8%～ 14 .4 % ,平均 11.2 %。足部…     

富血小板凝胶在糖尿病足溃疡治疗中的应用

富血小板凝胶是近年来新出现的辅助治疗糖尿病足溃疡(DFU)的方法之一.局部应用富血小板凝胶治疗DFU可有效改善DFU的难愈合性并提高溃疡愈合率,且无明显不良反应发生;也可降低截肢率,且没有增加医疗总费用.富血小板凝胶治疗DFU的作用机制可能与其中富含的生长因子、细胞因子和白细胞等有关,还可能与凝胶超微结构、溃疡中基质金属蛋白酶的变化有关.     

老年糖尿病足防治的重要原则

糖尿病足的定义是发生于糖尿病患者的与局部神经异常和下肢血管病变相关的足部感染、溃疡和／或深层组织破坏。糖尿病足病是严重的糖尿病慢性并发症,从足皮肤到骨与关节的各层组织均可受累,严重者町以发生局部的或全足的坏疽,需要截肢。截肢可以严重地影响患者的生活质量,并增加对侧截肢的危险性。糖尿病足病可以迁延不愈,也可以发展迅速,短期内病情急转直下,严重致残,甚至死亡。糖尿病足病更多地发生于老年糖尿病患者,尤其是合并多种糖尿病并发症的老年患者。