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Category Archives: Diabetic Foot Management

foot odour

Foot Odour and Smelly Feet

The feet actively supporting the rest of the body, tend to be covered up all day. Thereby restricting the follow of air that helps reduce sweat and decrease bacteria activity on the feet.  Which can cause the feet to smell worse than other parts of the body. Smelly feet and foot odour can become problematic and if not treated accordingly leads to not only embarrassing moment, but affect your self confidence and freedom to wiggle those feet of yours

At one point in time we all tend to sweat and perspire on the feet  due to several reasons like those listed below. When these sweat itself can not evaporate then it leads to smell or stinking feet. This is usually caused by skin bacteria breakdown and secretes. Fungal infection, such as Athletes’ feet and other factors listed below can cause foot odour. 

To help prevent this condition of smelly feet or foot odour at the office, during sport practice, at your loved ones home or just simply stretching your feet out at garden or when having a picnic at the park. Dr. Babajide Ogunlana has a few tips: 

  • Avoid  the use of shoes that are tight to the feet as this can help reduce heat that makes the feet sweat and feed the growth of bacteria. Doing this also helps to avoid you developing conditions such as  bunions, toes fungus and corns and callus.
  • Clean your feet regularly with soap and water at least once a day and more if you do rigorous activities such as exercising, running , sport and walking. Take your time to dry your feet thoroughly afterwards, especially between your toes.
  • Have an extra pair of shoes so that you can rotate your shoes daily. This will give them a chance to air and dry at least 24 hours before the next wear. You can use Clean Sweep an antimicrobial Shoe Protection Shield, clinically proven to inhibit the growth of odor-causing bacteria, fungus, and mold. In your shoes at the end of the day after wearing them. Antiperspirant spray  or deodorant can help your feet stay dry or the use of foot powder to absorb sweat from your feet.
  • Use wool or cotton socks  preferably  and not nylon,  as they help to  absorb moisture better. Change your sock at least once a day, use sports socks and medicated insoles that are made to keep feet dry, and special antibacterial socks, which have a deodorising effect for your feet and shoes.
  • Avoid going barefoot in public space and communal facilities like gyms, bathing places and swimming pools. It is very easy to pick up germs, such as bacteria, fungus, and warts
  • Wear flip flops and when practicing yoga, clean your feet with antiseptic wipes or hygienic baby wipes in case you don’t have access to a shower right after class.
  • Good foot hygiene is essential , keep toenails trim and clean and remove callused skin with a foot file. Get a foot soak like using a salt bath, tea soaks or apple cider vinegar will help with callused skin and bacteria.

 

  • Reduce and if possible avoid the consumption of refined carbohydrates. Instead, take a balanced diet, with enough fruits & veggies and plenty of water.  

Condition that can lead to such foot odour and smelly foot are; 

  • Fungal Infection
  • Standing All Day 
  • Overactive Sweat Glands
  • Genetics
  • Injury Due To Structural Tissue
  • Bacterial  Breakdown On Skin
  • Hormonal Changes
  • Daily Stress
  • Poor Personal Hygiene 
  • Wearing Same Shoe Everyday Without Airing Them

Does Psoriasis Or Fungal Infection Make Patients More Vulnerable To COVID-19?

The authors of a recent study suggest that patients with some dermatologic diseases, such as superficial fungal infections and psoriasis, may be at higher risk for the COVID-19 virus, due to a possible similarity between cutaneous and mucosal immunity.

In the study, published by Dermatologic Therapy, researchers assessed dermatological comorbidities of 93 patients with the COVID-19 virus. They found that the most common skin conditions in this patient cohort in the past three years were superficial fungal infections (25.8 percent), seborrheic dermatitis (11.8 percent), actinic keratosis (10.8 percent), psoriasis (6.5 percent) and eczema (6.5 percent).

In addition, 17 of the patients in the study also presented to the dermatology clinic in the last three months. Among this subcohort, the most common dermatological conditions included superficial fungal infections (25 percent), psoriasis (20 percent) and viral skin diseases (15 percent).

Tracey Vlahovic, DPM, FFPM, RCPS (Glasg), says the study authors have made broad assumptions and do not mention other comorbidities or contributing factors. She adds that the study is also problematic since it combines groups receiving topical and systemic/biologic therapy, and suggests that both groups are at risk. Dr. Vlahovic, who is board-certified by the American Board of Foot and Ankle Surgery, recommends monitoring the National Psoriasis Foundation and the International Psoriasis Council websites for guidance.

“The National Psoriasis Foundation recommends those who are on systemic and/or biologic therapy should remain on therapy unless they develop a COVID-19 infection. Patients who have other comorbidities should speak with their physicians regarding staying on their current treatment or changing it,” maintains Dr. Vlahovic, an Associate Professor in the Department of Podiatric Medicine at the Temple University School of Podiatric Medicine.

Joel Morse, DPM agrees that the premise that those with fungal infections or inflammatory skin disease are more likely to contract COVID-19 is suspect.

He wonders if major comorbid conditions such as diabetes could be contributing to an increased risk of developing the COVID-19 virus. Can the virus move through the skin if the stratum corneum is compromised? These are important questions to consider, says Dr. Morse, a Past President of the American Society for Foot and Ankle Dermatology.Does Psoriasis Or Fungal Infection Make Patients More Vulnerable To COVID-19?

Annette Joyce, DPM concurs that this study has limitations including: a small sample size; lack of specificity as to the location and type of fungal infections involved; and failure to link immunosuppression specifically to these superficial fungal infections.

“Fungal infections of the nails and skin are harder to treat in some patients due to immune system phenotype,” says Dr. Joyce, the Medical Conference Chair for the DERMfoot conference.

Dr. Joyce also notes that organ-specific immune response in the evolving knowledge of antifungal immunity could play a role in future immune-based COVID-19 therapies, but there are still so many unknowns.

Dr. Morse advocates for investigation of other viruses in patients with skin disease, and whether this heightens the risk for infection.

“When someone is in the hospital with COVID-19 life- and limb-threatening issues, we are probably not looking for tinea pedis or scaling on the elbow … but maybe we should,” suggests Dr. Morse, who is board-certified by the American Board of Foot and Ankle Surgery.

 

 

Can Adding Plantar Plate Repair To A Metatarsal Osteotomy Yield Better Results For Fo

refoot Metatarsalgia?

Regardless of the degree of plantar plate injury, adding a plantar plate repair to a shortening second metatarsal osteotomy may improve outcomes, according to a recent study published in the Journal of Foot and Ankle Surgery. 

In a prospective study, the authors evaluated 86 adult patients who had second metatarsal Weil osteotomies with and without concomitant plantar plate repair for sub-second metatarsal head pain over a 3.5-year period, and followed them for one year. Patients in the group who had a plantar plate repair with their second metatarsal osteotomy showed better foot-specific quality of life and pain scores at one year despite this group having more severe baseline injuries to the plantar plate. Researchers noted no difference in pre- or postoperative radiographic parabolas, second toe alignment or complication rates between the two groups.

Adam Fleischer, DPM, MPH, FACFAS, the lead author on the study, shares that after successful plantar plate repair from a dorsal approach, he observes patients are less “aware” of their previous foot ailment, which correlates with a higher level of confidence and higher quality of life scores.

Erin Klein, DPM, MS, AACFAS, a co-author of the study, finds in her practice that repairing the plantar plate helps with stability of the MPJ as well as pain.

Dr. Fleischer notes that in his experience, magnetic resonance imaging (MRI) and ultrasound both correlate closely with intraoperative evaluation of the extent of plantar plate injury, which he finds helpful during operative repair.

Dr. Klein agrees. She elaborates that a special MRI protocol with 0.2 to 0.3 mm slices through the metatarsal head/plantar plate region will help the surgeon understand the pathology much better.

“Correcting instability by repairing the plantar plate and then addressing the deforming osseous force (metatarsal length) provides pain relief and improved function postoperatively,” explains Dr. Klein.

Lowell Weil, Jr., DPM, MBA, FACFAS, a co-author of the study, emphasizes the clear necessity to address and correct metatarsal length.

“The plantar plate is a truly important structure that one should repair appropriately when pathology is present,” notes Dr. Weil, CEO of the Weil Foot and Ankle Institute. “Doing this combined procedure yields the highest level results in our research.”

“If patients demonstrate clinical instability of the lesser metatarsophalangeal joint and require a Weil osteotomy, (I recommend) a low threshold for anatomic repair of the plantar plate,” says Dr. Fleischer, who likens it to mechanical instability of the lateral ankle, which benefits from imbrication and advancement of the native tissues.

 

Are There Identifiable Trends In The Organisms Involved In Osteomyelitis?

What organisms might one expect to see upon bone biopsy in cases of osteomyelitis? A new study in the Journal of Foot and Ankle Surgery takes a closer look at patterns that may help in prescribing effective antibiotics.

Reviewing two random cohorts of 151 patients each in 2005 and 2010, the authors examined demographics, comorbidities, microorganisms found on bone biopsy and culture, location and pre-biopsy antibiotic use. Gram-positive bacteria, specifically methicillin-sensitive Staphyloccus aureus (MSSA), was most common in both groups. However, methicillin-resistant Staphyloccus aureus (MRSA) decreased from a prevalence of 28.3 percent to 10.6 percent from 2005 to 2010.  The most common gram-negative bacteria was the Pseudomonas species and patients with peripheral vascular disease exhibited a higher incidence.

Mitzi Williams, DPM, FACFAS, one of the authors on the study, was not surprised by the results as they align with her clinical experience.

Regarding the reduction in MRSA between 2005 and 2010, Dr. Williams personally feels the reason is multifactorial and could include antibiotic stewardship and striving to minimize admissions and returns to the operating room.

Windy Cole, DPM agrees that the findings correlate with her clinical practice. She adds that S. aureus is readily found in the environment as well as the normal skin flora of healthy individuals.

“It is when the bacteria enter into the deep tissues or bloodstream that potentially serious infections can occur,” explains Dr. Cole, the Director of Wound Care Research at Kent State University College of Podiatric Medicine.

MRSA infection reduction could also be attributed to better hygiene, sterilization and cleaning techniques in the hospital setting and the community, adds Dr. Cole.

Dr. Williams also feels podiatrists approach amputations in a way that prevents future infection.

“We recognize that removal of a central ray will likely result in a transfer lesion and may subsequently become infected,” notes Dr. Williams. “Hence, we do not simply remove what is infected. We perform a functional amputation, which carries lower long-term risks.”

Dr. Cole adds that bone biopsies and deep tissue cultures are the foremost way to isolate pathogenic bacteria and form the best treatment plan.

Currently, empiric antibiotic use should cover MSSA, says Dr. Williams, a Diplomate of the American Board of Foot and Ankle Surgery. Careful analysis for a history of MRSA, chronic ulcerations or a finding of liquefactive necrosis may lead one to redirect empiric therapy. She adds that one should choose empiric antibiotics based on the most likely organism(s) involved

May 27, 2020
Pages: 10 – 11
By Jennifer Spector, DPM, FACFAS, Associate Editor
plantar plate tear repair

Current Best Practices In The Treatment Of Plantar Plate Tears

After 20 years in practice, I have found that one of the more complicated issues is the treatment of lesser metatarsophalangeal joint (MPJ) instability. The MPJ is a very complicated joint, which is connected by collateral ligaments and pulled on by multiple external and internal foot tendons. All of these can cause strain on the joint and be sources of deformity and pain.

A common problem causing instability of the lesser MPJ is a plantar plate injury. Overall, there have been significant advances over the years in repairing the plantar plate but correcting hammertoes with complicated MPJ instability continues to be challenging.

Key Diagnostic Considerations Plantar Plate Tears

It is essential to listen closely to patients in order to understand their concerns and needs. Not every patient needs surgery or has pain that requires extensive repair. Most patients are more concerned initially with the new and worsening pain under the metatarsal head. They will sometimes note their toe is starting to shift. Patients with more long-standing pain will often have a more severe shift of the toe and even a crossover toe syndrome (most commonly the second toe crossing over the great toe). Overall, it is vital to understand what the patient expects. A stiff but straight toe after an arthrodesis may not be what the patient needs.

Most commonly, the patient wants to be pain-free and perform his or her normal activities. However, in addition to concerns about pain and toe position, one needs to ask more subtle, specific questions of the patient. Does the patient have difficulty in all shoes or just a certain type? What activities does the patient prefer and does a stiff toe preclude that activity? These questions will ultimately help with treatment selection.

The physical examination also needs to be fairly detailed. When a dorsal drawer test reveals instability of the toe, this is a sign that the plantar plate is lax or partially torn. However, we need to ascertain more information to inform our treatment plan. Is there a tendon imbalance? Is there more weakness on one side of the toe versus the other, suggesting only a partial plantar plate tear? What is the level and rigidity of the digital contracture? Is the metatarsal head very prominent? Finally, is there a bunion deformity, causing overloading of the second MPJ?

Diagnostically, standard radiographs are a good start. The goal is to see the general position of the foot and bone architecture. Furthermore, metatarsus adductus and the level of toe deviation are also important factors along with the size and extent of any present bunion deformity.

If surgical intervention is a consideration, obtaining a magnetic resonance imaging (MRI) study of the foot can help the surgeon assess the level of plantar plate tear, check for a neuroma and also ensure the articular surfaces are not badly damaged. Plantar plate damage can be subtle. The surgeon should interpret the MRI as well, not just the radiologist. Get to know your radiologist and explain what you are looking for as the radiologist may not know what you suspect or be as familiar with the intricacies of the plantar plate.

Evaluating Non-Surgical Approaches To Plantar Plate Tears 

Unless the patient has significant deformity, one should first attempt non-surgical care. For acute pain less than three months in duration, patients may respond to plantarflexory strapping of the toe and the use of a stiff shoe or boot to prevent strain. Physical therapy and oral steroids are also options. I do not recommend using a steroid injection as this can cause further damage and rupture to the plantar plate.

When it comes to more chronic and non-inflammatory pain that is greater than three months in duration, I prefer to add a platelet-rich plasma (PRP) or amniotic injection to the region to increase healing potential. Anecdotally, I have found this to be successful in early cases. Clinicians must convey to patients that strapping, the use of a boot or injection treatments will not correct the toe position. Again, this is why it is critical to understand the patient’s needs and expectations.

For many older or sedentary patients, fitting into shoes is impossible due to severe toe contracture. Strapping alone may improve this. For patients in this population who have a severe bunion and medially deviated third toe with a dislocated second toe, one might consider a second toe amputation.

Assessing Current Surgical Options For Plantar Plate And Hammertoe Repair plantar plate tear repair

As I noted above, there have been significant advances in surgical repair of the plantar plate. The question is what works and what does not. I have experience with many systems, plantar and dorsal approaches, all with or without osteotomy or hammertoe correction.

The hammertoe contracture is an important deforming force. Correction of the hammertoe increases the plantar strength of the flexor tendons and helps with relocation of the toe. If there is a severe dorsal contracture, an extensor lengthening can help relax the dorsal strain. It is important to remember that if the toe is medially deviated as well, one must not neglect this during hammertoe correction. During my procedures, I prefer to preserve the length of the proximal interphalangeal joint (PIPJ) length and not use a saw. I primarily employ a cup and cone technique with a rongeur, and do subsequent rounding with a burr. I also try to keep the joint fairly tight but still maintain reducibility at the PIPJ so there is less gapping at final reduction.

My preferred implant is the Hammertoe Fixation System (Ossio), which is made out of a natural fiber material that incorporates easily into bone. There is no absorption and the material has a sticky quality, which keeps the bones from separating. It is also trimmable, allowing one to reduce length if the intermediate phalanx is smaller. Surgeons can also cut through this implant in case of revision or conversion to an arthroplasty. The implant can also go through an MRI without signal. I no longer use metal in my hammertoes as it is mainly intramedullary and is very difficult to remove without severe damage to the toe.

Salient Pearls For Assessing And Addressing MPJ Deformity And Dislocation 

When correcting the MPJ, one must consider the stability of the joint, the amount of medial deviation, partial versus complete plantar plate tears and the amount of time that has passed since complete dislocation. The MRI and exam should help with decision making.

I divide my cases into mild, moderate and severe dislocations. A mild dislocation is a somewhat unstable joint with a very mild medial shift of the toe and very little dorsal contraction. A moderate case is one with a fairly lax joint on a dorsal drawer test and enough medial deviation that the great toe and second toe are touching or mildly overlapping. A severe case has significant medial deviation with crossover of the second toe or a complete plantar plate tear and dislocation at the MPJ. Each of these categories has some overlap so be prepared to treat and classify in a fluid fashion.

A metatarsal osteotomy and a possible extensor lengthening are often applicable in mild cases. I try to avoid a tenotomy because transfer of strain to the other digits may cause them to contract over time. I find extensor lengthening to be far better. The biggest pearl for my metatarsal osteotomies is to shift the metatarsal medially and shift the toe laterally, much like a bunion correction. I will, at times, imbricate the lateral capsule and collateral ligament for mild cases. In these instances, there is very minimal plantar plate tear and therefore, I find no need to repair it. It will heal during the post-surgical period and there is less stiffness of the joint without repair.

Moderate cases require plantar plate repair. Performing a metatarsal osteotomy shifts the metatarsal medially to help with repositioning the toe. One should examine and repair the plantar plate prior to repair of the metatarsal. A majority of plantar plate tears are lateral or central-lateral. I do not free up the entire plantar plate as I find this causes a great deal of scar tissue. I prefer to release the lateral plantar plate in the region of the tear, remove a triangular wedge and then utilize one of the plantar plate repair systems.

My system of choice currently is the Hat-Trick Lesser Toe Repair System (Smith & Nephew). I utilize the full repair system and pass two sutures, one on the medial side of the repair site and one on the lateral edge. I pass these two sutures through one or two holes, and hold them in place with PEEK interference fixation. More often than not, I use a single hole from lateral to medial and pass the sutures through that hole with one interference pin to stabilize the joint. The Hat-Trick system provides me with better correction of the medial deviation and less scarring. It is very rare for me to perform a flexor tendon transfer for a moderate case but I suggest being comfortable with it in case of poor plantar plate quality or if damage is apparent during repair.

A severe case either has a great deal of medial deviation or dislocation. In such cases, I find the plantar plate is either very poor quality or non-existent. For these patients, I now perform a flexor tendon transfer as I find it far more reproducible and successful in stabilizing a severe joint shift. I harvest the flexor tendon at the PIPJ prior to performing my hammertoe fusion. One then splits the tendon and pulls it medially and laterally along the proximal phalanx to the base of the toe on either side. The surgeon should place the tendon directly against the bone in order to avoid neurovascular damage before tensioning it and placing a single temporary stitch to hold it.

One subsequently positions and stabilizes the metatarsal in the osteotomy region. Holding the toe in position, the surgeon crosses the tendon ends over each other and adjusts tension on each side until the toe is stable and well-positioned at the MPJ. I use a 3-0 taper needle to place three double-pass stitches through the tendon to stabilize it. Then I tie the end sitting on the lateral side of the toe to the MPJ lateral capsule for additional stability and fine-tuning of the crossover toe correction. I do not use a K-wire across the MPJ and prefer to strap the toe with dressings for stability. You may have the patient begin MPJ range of motion at week two or three to prevent scar formation and joint stiffness.

A metatarsal osteotomy is usually, if not always, necessary as are hammertoe correction and extensor tendon lengthening. One may employ strapping and dressings to facilitate stabilization until suture removal. After removing the sutures, a toe strap should suffice. I like the Darco TAS Toe Alignment Splint (Darco) as it is very solid, can also incorporate a bunion splint and has an elastic band around the midfoot that decreases edema. However, any splint that prevents toe dorsiflexion is okay.

What You Should Know About Avoiding Post-Op Stiffness And Floating Toe 

About 20 percent of patients will still have a floating toe at three to six months postoperatively and will require an in-office tenotomy and capsulotomy of the MPJ to reduce dorsal scarring and contracture. These procedures have proven to be very good adjuncts in my patients.

I find flexor tendon transfers rarely result in a floating toe but there is a bit more stiffness. As I noted above, one can have patients initiate gentle and stabilized range of motion of the MPJ with practicing of grip strength of the MPJ. Range of motion can be more aggressive in weekly increments with physical therapy highly recommended. Wrapping the toe with a Coban wrap for two to three months is essential to avoid swelling. A Coban wrap for the midfoot is helpful but far less important than it is for the toe.

In Conclusion 

Proper planning and a solid understanding of different surgical options will make plantar plate and hammertoe repairs gratifying and fairly reproducible treatments for patients. Although plantar plate repair can be difficult, it is important for the surgeon to have a comprehensive mastery of options as one procedure does not fit every patient case.

Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Director and Fellowship Director at the University Foot and Ankle Institute in Los Angeles (https://www.footankleinstitute.com/podiatrist/dr-bob-baravarian). 

Dr. Baravarian has disclosed that he is a consultant for CrossRoads Extremity Systems and OSSIO. 

May 11, 2020
Pages:30 – 32
By Bob Baravarian, DPM, FACFAS
Diabetic Foot Ulcers

Can Remote Ischemic Conditioning Promote Healing In Diabetic Foot Ulcers?

The prevalence of diabetes is on the rise worldwide. As podiatrists and diabetic foot experts, we know the deleterious effects of diabetes on the tissues of the lower extremity. Among diabetes-related complications, the treatment and management of diabetic foot ulcers (DFUs) remains major challenges for patients, caregivers and health-care systems alike. Multiple disrupted physiologic processes, including decreases in cellular signaling and growth factor responsiveness, lead to microvascular dysfunction and diminished peripheral blood flow that can contribute to the lack of healing in people with DFUs.

Successful translation of novel therapeutic modalities into clinical algorithms for DFU management may fulfill an unmet need that is of increasing importance given the global diabetes epidemic. There is an abundance of clinical evidence that remote ischemic conditioning is cardioprotective but can it provide the same protection to the microvascular circulation of patients with diabetes, and accordingly help increase healing rates in patients with DFUs?

Researchers initially studied remote ischemic conditioning (RIC) as a potential protective strategy for cardiac function. In 1986, Murry and colleagues discovered that short repetitive bouts of occlusion and reperfusion of a coronary artery in dogs subsequently protected the heart against a myocardial infarction.1 In 1993, Przyklenk and team conducted a study that is considered the first evidence for the remote application of tissue conditioning.2 This study showed that brief controlled periods of occlusion and reperfusion of a canine coronary artery also protected remote cardiac tissue not directly supplied by this artery when subjected to a subsequent sustained ischemic episode.

Drawing upon on this data, researchers began investigating whether remote ischemic conditioning provided analogous benefits to patients with tissue ischemia injuries. Subsequent clinical studies in human models have concluded that remote ischemic conditioning is safe, well-tolerated and produces a systemic phenomenon that has beneficial effects in other organs such as lung, liver, kidney, intestines and the brain as well as skeletal muscle tissues.3,4

 

What The Research Reveals About Endothelial Dysfunction, Microvascular Disease And Remote Ischemic Conditioning

Ischemic Conditioning Promote Healing In Diabetic Foot Ulcers?While the prevailing thinking is that the etiology of diabetic microvascular disease is multifactorial, a consistent finding in patients with diabetes is endothelial dysfunction.5 There is a known correlation between the long-term effects of elevated glucose levels and the alteration of endothelial cell function.5 An impairment in the formation of vasodilators such as nitric oxide along with increases in the formation of several vasoconstrictors speed the progression of microvascular disease.6 It is generally accepted that hyperglycemia resulting from uncontrolled diabetes leads to an impairment of nitric oxide production and activity.6,7 Prolonged elevated glucose levels generate oxidants in smooth muscle that may diminish nitric oxide signaling, decreasing the responsiveness of endothelium-dependent vasodilation, especially in the microcirculation.6,7 The effects of this cascade of events are decreased functional perfusion and tissue hypoxia in the lower extremity, particularly the feet, complicating DFU healing.

There is scientific evidence indicating that one effect of remote ischemic conditioning is an increase in nitric oxide production.7 One hypothesis is that the repetitive inflation and deflation of a blood pressure cuff has a shearing effect on the vasculature that results in the release of nitric oxide.7 Researchers have suggested that remote ischemic conditioning may contribute to improved endothelial function, resulting in enhanced vascular performance.7 Reversal of tissue hypoxia and increases in peripheral circulation could potentially improve wound healing, especially in patients who are not candidates for other vascular interventions.

In a 2011 study, Kraemer and colleagues treated 27 healthy patients with remote ischemic conditioning and examined tissue oxygenation and capillary blood flow in the anterolateral aspect of the left thigh.8 After patients had three five-minute cycles of remote ischemic conditioning to the contralateral upper arm, researchers found statistically significant increases from baseline measurements of 29 and 35 percent in tissue oxygenation and capillary blood flow respectively. These increases occurred during the third reperfusion phase.8 The results of this study appear to support evidence of increased microvascular blood flow in the lower extremity, furthering the idea that remote ischemic conditioning could potentially aid in DFU healing.

In a 2014 double-blind, prospective, randomized study involving 40 patients with aseptic and infected DFUs, Shaked and colleagues assessed the efficacy of remote ischemic conditioning as an adjunct to standard of care treatment.9 Applying blood pressure cuffs to both arms of all the patients, researchers inflated and deflated the cuffs for three five-minute cycles. The study group had their cuffs inflated to 200 mmHg while the control group had their cuffs inflated to 10 mmHg. The patients in the study group had remote ischemic conditioning treatments every two weeks and were followed for a total of six weeks. For the patients who completed the study, nine out of 22 patients (41 percent) in the treatment arm achieved complete wound healing in comparison to zero out of 12 patients in the control group.

 

Could Remote Ischemic Conditioning Have An Impact In Limb Salvage Protocols? 

Most clinical remote ischemic conditioning treatment studies use a standard blood pressure cuff or similar device applied to the upper or lower extremity to produce the cycles of non-lethal ischemia. Treatment typically consists of three or four cycles that medical personnel can administer over approximately 40 minutes by inflating and deflating the blood pressure cuff every five minutes. Clinicians reportedly achieve the greatest effects with treatments every 72 hours or two to three times a week.10

The occlusion pressure needs to be at least 25 mm above the patient’s systolic pressure, which averages 125 mmHg but can be much higher.10 Therefore, medical personnel need to determine the patient’s systolic pressure first and monitor it throughout treatment. One option is to go arbitrarily high on all patients but even a set pressure of 200 mm leaves nine percent of patients with DFUs uncovered and is very uncomfortable for all patients, potentially reducing compliance.10 Thus, integrating such treatments into regular clinical practice would be costly in time and medical staff resources as well as patient satisfaction.Remote-Ischemic-Conditioning

An emerging modality, the HomeCuff Wound Therapy device (LifeCuff Technologies), is reportedly showing promise in early studies.11 According to the company, this automated remote ischemic conditioning device is specifically designed for home use with easy application to the arm by the patient or a caregiver. The modality operates through a single push-button, which is pre-programmed to deliver an automated 40-minute treatment cycle without the need for medical personnel, thus reducing the cost of treatment. Unlike standard blood pressure cuffs that can only apply a single set pressure, the HomeCuff Wound Therapy device applies variable occlusive pressure based on intermittent readings of extremity blood pressure from software within the cuff.10,11 This facilitates the delivery of remote ischemic conditioning at the most effective yet comfortable level.10,11

The device has a built-in electronic monitoring system that collects and transmits adherence to treatment regimen data and vital sign values to a secure and HIPAA-compliant database. Early case studies showed promising results with the use of the HomeCuff Wound Therapy device two to three times weekly to treat patients with DFUs.10

 

How Remote Ischemic Conditioning Helped Heal An Ulcer Of Three Months In Duration 

A 68-year-old male presented with a three-month history of a neuropathic ulcer (4.75 cm2) to the left first metatarsal head (see first photo above). His past medical history included non-insulin-dependent diabetes mellitus (NIDDM), diabetic neuropathy, stage 3 cardiovascular disease, cirrhosis, anemia and hepatic encephalopathy. The patient previously tried and failed multiple advanced wound care therapies before using the HomeCuff Wound Therapy device. He began 40-minute treatments with this modality three times weekly. Secondary wound dressings consisted of Drawtex® hydroconductive wound dressing (Beier Drawtex Healthcare), ABD padding, rolled gauze and Coban. The wound completely healed in seven weeks (see second photo above).

 

Concluding Thoughts 

Preliminary case study results utilizing remote ischemic conditioning as an adjunctive therapy in the treatment of hard-to-heal DFUs appear promising. Further research into remote ischemic conditioning is necessary in order to prove its utility in wound care. A full understanding of preclinical data as well as the methods and mechanisms involved with remote ischemic conditioning will help wound care clinicians determine when and if to employ remote ischemic conditioning as an adjunctive therapy. Randomized clinical trials may help facilitate the translation of such new technologies to a clinically feasible paradigm for home use.

Dr. Cole is the Medical Director of the Wound Care Center at University Hospitals Ahuja Medical Center in Beachwood, Ohio. She is also an Adjunct Professor and Director of Wound Care Research at the Kent State University School of Podiatric Medicine. 

Ms. Coe is a Clinical Research Coordinator in Wound Care Research at the Kent State University College of Podiatric Medicine. Since 2015, she has been a Certified Clinical Research Professional through the Society of Clinical Research Associates (SOCRA). 

References

1. Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation. 1986;74(5):1124-36.

2. Przyklenk K, Bauer B, Ovize M, Kloner RA, Whittaker P. Regional ischemic ‘preconditioning’ protects remote virgin myocardium from subsequent sustained coronary occlusion. Circulation. 1993;87(3):893–899.

3. Vasdekis SN, Athanasiadis D, Lazaris A, et al. The role of remote ischemic preconditioning in the treatment of atherosclerotic diseases. Brain Behav. 2013;3(6):606–616.

4. Lim SY, Hausenloy DJ. Remote ischemic conditioning: from bench to bedside. Front Physiol. 2012;3:27.

5. Avogaro A, Albiero M, Menegazzo L, de Kreutzenberg S, Fadini GP. Endothelial dysfunction in diabetes: the role of reparatory mechanisms. Diabetes Care. 2011;34 Suppl 2(Suppl 2):S285– S290.

6. Cohen RA. Role of nitric oxide in diabetic complications. Am J Ther. 2005;12(6):499–502.

7. Kimura M, Ueda K, Goto C, et al. Repetition of ischemic preconditioning augments endothelium-dependent vasodilation in humans: role of endothelium-derived nitric oxide and endothelial progenitor cells. Arterioscler Thromb Vasc Biol. 2007;27(6):1403–1410.

8. Kraemer R, Lorenzen J, Kabbani M, et al. Acute effects of remote ischemic preconditioning on cutaneous microcirculation–a controlled prospective cohort study. BMC Surg. 2011;11:32.

9. Shaked G, Czeiger D, Abu Arar A, Katz T, Harman-Boehm I, Sebbag G. Intermittent cycles of remote ischemic preconditioning augment diabetic foot ulcer healing. Wound Repair Regen. 2015;23(2):191–196.

10. Personal communication with Thomas Moore, BA, Chairman and CEO of LifeCuff Technologies, on January 9, January 11 and February 27, 2020.

11. Garratt KN, Leschinsky B. Remote ischemic conditioning: the commercial market: LifeCuff perspective. J Cardiovasc Pharmacol Ther. 2017;22(5):408–413.

April 28, 2020
Pages: 12 – 16
By Windy Cole, DPM and Stacey Coe, BA, CCRP
Is Total Ankle Replacement Appropriate In Cases Of Severe Coronal Deformity?

Is Total Ankle Replacement Appropriate In Cases Of Severe Coronal Deformity?

Although preoperative coronal deformity greater than 20 degrees has historically been a contraindication for total ankle replacement (TAR), a recent study in the Journal of Bone and Joint Surgery contends that this is not necessarily true.

The study authors assessed 148 ankles after TAR and noted that 41 ankles had severe coronal deformity over 20 degrees. Employing radiographic and clinical evaluation, the authors compared outcomes between severe and moderate deformity groups. After a mean of 74 months follow-up, there was no significant difference in pain scores, disability scores, range of motion or complication rates between those with severe and moderate deformities. Postoperative tibiotalar angle and talar tilt angle were greater in the severe deformity group.

Ryan McMillen, DPM, FACFAS relates that he tries to perform TAR on congruent ankle joints, pointing out that implant survivorship is not the only consideration.

“It’s also about edge loading and how it develops in joints with at least 10 degrees of coronal deformity,” explains Dr. McMillen, a member of the faculty for the Western Pennsylvania Hospital Foot and Ankle Residency Program in Pittsburgh. “This can lead to a need for poly exchange or abnormal wear on the implant.”

Mark Prissel, DPM, FACFAS, shares that large valgus deformities are more challenging and may require a staged approach, especially if they are associated with a flatfoot deformity and/or deltoid insufficiency.

Dr. McMillen agrees that ligamentous balancing may be required with these larger deformities and notes that he has seen no increase in complications in the short and intermediate terms with this balancing.

While this study showed similar results among the cohorts studied, Dr. Prissel says this may not be true in lower volume centers.

“Complex TAR with large angular deformity should be performed by experienced TAR surgeons at centers of high volume,” maintains Dr. Prissel, who is in private practice with multiple locations in Ohio.

Dr. McMillen adds that a comparison to patients with low to no coronal deformity would have been interesting to see with this study. He acknowledges that this study could cause him to more closely consider a patient for TAR who has more than 10 degrees of deformity and is otherwise a strong candidate for the procedure.

Study Says Younger And Less Active Patients More Prone To Sever’s Disease

A recent study in the Journal of the American Podiatric Medical Association found that younger (mean age 9.8 years) and less active (sports sessions less than 60 minutes) patients are more likely to suffer from calcaneal apophysitis.

The study included 430 children (328 male, 102 female) aged six to 14 years old. Most of the children participated in sports a mean of 2.8 times per week with each session being 60 to 120 minutes for most respondents. In addition to the primary findings regarding age and activity level, the study authors did not identify any significant differences with regard to sex, foot posture, BMI, terrain type or type of sport.

Stephen Kominsky, DPM, FACFAS says a keen understanding of the biomechanics of Sever’s disease is key to successful outcomes. Maggie Fournier, DPM, FACFAS echoes the importance of biomechanics.

When asked about the typical patient profile in their practices with calcaneal apophysitis, both doctors have had similar clinical experiences seeing males around 11 years old in high-impact or running sports. However, age, gender and activity level may vary.

Dr. Kominsky shares that this study will not change his current patient treatment protocols.

“I believe that treatment should be broken down into activity modification, mechanical support … and non-steroidal anti-inflammatory drugs (NSAIDs),” notes Dr. Kominsky, the former Director of Podiatric Medical Education at the Washington Hospital Center in Washington, DC. “Then, based on availability, things like physical therapy, laser and stretching/yoga can be of additional benefit.”

Relating that this study reinforces her current protocol for Sever’s disease, Dr. Fournier explains that a thorough history and sound physical examination should lead to a correct diagnosis without the need for additional imaging (unless there is concern of additional or different diagnoses).

“I do not hesitate to utilize ancillary services such as those provided by athletic trainers or physical therapists,” notes Dr. Fournier, the Immediate Past President of the American Academy of Podiatric Sports Medicine. “(Calcaneal apophysitis) can be a lingering and frustrating issue due to varying responses to treatment and continued sports demands on the patient.  However, we should not hesitate to modify our treatment plans to provide the most effective care.”

Study Looks At Umbilical Tissue In DFUs With Osteomyelitis

Could cryopreserved umbilical cord be an emerging option for complex, non-healing DFUs with osteomyelitis? A recent study in Wound Repair and Regeneration evaluated the use of such tissue (TTAX01) for these complex cases.

Over a 16-week trial involving 32 patients with DFUs and underlying osteomyelitis, researchers performed initial surgical debridement and then the patients had a combination of systemic antibiotics with application of TTAX01. Patients received repeat applications of TTAX01 at no less than four-week intervals. The authors reported no major amputations and noted a 91 percent mean wound area reduction from baseline.

Eric Leonheart, DPM relates treating countless DFUs and osteomyelitis over 25 years in practice. Although he has not used umbilical cord biologics, Dr. Leonheart shares he would only use biologic graft materials in complex wounds (exposed tendon, muscle, joint and bone) that are osteomyelitis-free.

Stephanie Wu, DPM, MSc, FACFAS, a co-author of the study, says most advanced biologics are not indicated for complex, deep wounds with osteomyelitis.

“It is rare to see a trial that focuses on complicated, deep, diabetic foot ulcers that extend to muscle, capsule or bone with radiographic evidence of osteomyelitis. There is truly a need for research (such as this) to assess the efficacy of novel biologic treatments to improve and accelerate healing in these complex wounds,” says Dr. Wu, the Associate Dean of Research, a Professor of Surgery at the Dr. William M. Scholl College of Podiatric Medicine and a Professor of Stem Cell and Regenerative Medicine at the School of Graduate Medical Sciences at the Rosalind Franklin University of Medicine and Science.

Dr. Leonheart finds the study’s suggestion that TTAX01 may be a possibility for DFUs with osteomyelitis concerning, citing a lack of detailed information on infection staging, debridement and management along with a lack of control group.

“I am a firm believer in the principles of umbilical and placental biologics when it comes to augmenting compromised wound healing. However, I would not change my way of treating these complex infections based on the findings in this publication,” states Dr. Leonheart, who is affiliated with the Department of Orthopedics at Madigan Army Medical Center in Tacoma.

Dr. Wu states that it is important to note that this study is not a large-scale, randomized, controlled trial, and that one purpose of this study was to examine the operational aspects and ease of compliance with the study protocol before initiating a larger, phase 3 study.

“We look forward to the confirmation of these findings in larger studies involving randomized comparison to other treatment strategies,” adds Dr. Wu.

November 25, 2019
Pages:10 – 11
By Jennifer Spector, DPM, Associate Editor
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