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Category Archives: Diabetic Foot Management

Spotting Diabetes (Mellitus) Early: Signs and Symptoms

Diabetes (Mellitus) Early: Signs and Symptoms

Some signs let you know if you have diabetes mellitus and give you a chance to start treatment early before things get too detrimental. These signs depend on what kind of diabetes mellitus you might have. Diabetes means “excessive urination” and mellitus means “honey”, these two words together mean “sweetness in urine” or in other words “sugar/glucose appearing in urine”. Many forms of diabetes mellitus are due to different causes.

Diabetes may be primarily—caused by another disease, or secondary—caused by damage of the pancreas by another disease. Approximately 98% of diabetes patients have primary diabetes mellitus, the idea behind this article is to help learn about the two kinds of primary diabetes: Type 1 and Type 2 diabetes.

Insight and self-consciousness, make it mainstream to ponder the wholeness of our health. There is an abundance of social media influencers advertising “eating plans” and “exercise regimens”. Lifestyle apps that keep you healthy by reminding you to drink water, recommending what best to eat and at what time, and ensuring you have enough breaks during the day.

Considering all these general mindfulness being the “in thing” in our society, it is alarming to see that so many people don’t understand the inner workings of their own bodies. So many people go through everyday life,  experiencing the symptoms of diabetes but take it as a normal occurrence because a large number of the symptoms do not present as dangerous on their own, and that in itself is its danger. Understanding and recognising some early symptoms of diabetes can help us understand when we need to seek some form of medical consultation.

Early Symptoms Of Diabetes

what-is-dka-diabetic-ketoacidosis.pngThe most common signs of diabetes mellitus (both type 1 and type 2) are frequent thirst, excessive urination and increased hunger. The excess glucose (sugar) in your blood that isn’t absorbed into your body due to diabetes is diluted by water and gotten rid of by the kidneys. This is the reason for frequent urination.

Because a lot of water is accompanying the glucose on the way out, the body gets dehydrated. You become thirsty and drink a lot of water to replace what was lost. Glucose and other nutrients and food groups are necessary for daily life from your everyday meals. Because there is now less glucose in your body (it has been flushed out), you start to feel hungry and crave food to compensate for the lack.

This leads to a cycle of always eating and drinking without actually getting any of the benefits. Controlling your blood glucose levels and keeping them optimal makes it possible to live life normally, eating and drinking whenever you wish without a condition forcing you to.

It is sad to see that these symptoms are so often written off as ‘normal’, but it is understandable. A busy person will not think thirst or a little nausea is a big deal, and even the more severe symptoms closely resemble the symptoms of a common cold or flu that goes away on its own after some days of rest and many bowls of chicken soup.

Not enough people realise that all these signs hint at the body’s inability to absorb glucose, which is caused by a lack of or insulin resistance—the hormone that transports glucose to where it’s needed. To be on the safe side, if after being sick your thirst still lingers, a visit to the doctor should be the next thing on the list. One single blood test can clear years’ worth of doubt.

The human body extracts glucose from food to use it as fuel. Every process in the body requires it, like how a car needs gas to run. The cells, tissues, and organs get the glucose that’s digested in the stomach after it has been transported out by insulin. Therefore, without insulin, there would be no energy for you to do work. The body would stop functioning properly.

The unique combo of continuous thirst, frequent urination, and sudden weight loss are key signs of an increased amount of glucose in the blood. These three symptoms are common in both type 1 and type 2 diabetes. Type 1 and Type 2 diabetes are different branches of the same disease. They are both caused by problems regarding insulin. This difference between the two types is the reason why the rest of the symptoms begin to vary after the early stages.

In Type 1 diabetes, the pancreas does not produce enough insulin to transport all the glucose you eat to where it is needed, so the rest remains in the blood.

In Type 2 diabetes, the pancreas produces enough insulin but the body does not recognise it so it cannot use it, and that causes the glucose to remain in the blood.

Symptoms Of Type 1 Diabetes

Type 1 diabetes happens suddenly and at any age in life—but usually it occurs before the age of 40. It happens when the pancreas stops secreting insulin. It is caused by degeneration of the cells of the pancreas, damage to the pancreas due to autoimmune diseases, a congenital disorder of pancreas cells or destruction of those cells by viral infection.

When it occurs in infancy or childhood, it is called ‘juvenile diabetes’. It can take weeks or months for the pancreas to completely stop secreting insulin, but eventually, a normal, healthy person will become insulin-deprived and their glucose levels will shoot up to dangerous levels. A patient with Type 1 diabetes will become dependent on insulin injections for treatment so Type 1 diabetes is also called Insulin-dependent diabetes mellitus (IDDM).

Since the body can’t access the glucose in the blood, it begins to find alternate sources of energy and starts breaking down fat and muscle. The end products of this are ketones (ketoacids).

The abundance of these acids makes the blood more acidic and leads to acidosis. This will cause fatigue, lack of appetite, and confusion.  

When the ketone level in your blood is very high, your heart will begin to beat faster, and your breathing rate will increase. Your breath will have a sweet, fruity smell because of the many ketones present in the bloodstream—and at this stage, the amount would have reached a life-threatening level that can cause unconsciousness.


Symptoms Of Type 2 Diabetes

Type 2 diabetes is caused by a partial deficiency of insulin caused by the body’s cells not being able to receive the hormone even after it has been produced. It is the more common type of diabetes and usually occurs after the age of 40. Only a few forms of it required insulin as treatment. It can be controlled by taking oral hypoglycemics (drugs that make the body more receptive to insulin/increase insulin production). Because of this, this type of diabetes is also called noninsulin-dependent diabetes mellitus (NIDDM).

Insulin Resistance can be caused by genetic factors, stress, or lifestyle changes. Examples of these lifestyle changes are bad eating habits and lack of physical activity which leads to obesity. Physical activity helps a person burn glucose and makes their body more sensitive to insulin while being overweight increases insulin resistance (scientists aren’t completely sure why).

A patient with Type 2 diabetes does not need insulin in the beginning because the pancreas overproduces to compensate for the unreceptive cells—this is the reason why Type 2 diabetes often goes unnoticed for years. But eventually, the pancreas isn’t able to keep up and the glucose builds up in the blood even with insulin being constantly produced. Eating healthy, cutting back on sweets and losing excess weight helps control the glucose levels in a person with type 2 diabetes. Early treatment positively impacts and maintains a good quality of life.

Spotting Diabetes (Mellitus) Early: Signs and Symptoms

Complications Of Diabetes Mellitus

Diabetes Foot

Prolonged hyperglycemia (high blood glucose levels) damages the retinas of your eyes (which spoils your vision). When caught early, this condition is manageable, but if left untreated, Diabetic Retinopathy will cause permanent damage to the retina of the eyes. Not only this, high glucose levels can damage the kidneys (Diabetic Nephropathy) and nerves (Diabetic Neuropathy) of the body as well as hypertension and heart attack.

A person with diabetes is more prone to getting fungal infections, and when they are infected it is quite hard to treat. Yeast grows from sugar and is naturally occurring in the body but when too much yeast accumulates it causes pain and itching. It grows in moist and warm places like the mouth, the folds of the skin, the genitals, the eyes, and the foot (especially the toenails).

Without treatment, such infections can lead to blindness or become life-threatening when the yeast manages to get into the bloodstream of a patient who has a depressed immune system and spreads to other parts of the body.

The high blood glucose also causes slow wound healing due to lack of energy and the neuropathy of the nerves will prevent you from feeling pain sensations, so a lot of tiny wounds become ulcers and if left untreated can cause problems later on.

For this reason, it is always good to pay close attention to the state of your body and catch these signs and symptoms before they progress too far and become deadly. Early intervention and correction of elevated blood glucose can promote proper circulation and healing while preventing the onset of all these complications.


Juvenile Diabetes:

Young children aren’t able to properly convey the changes that occur in their bodies due to a lack of understanding or communication skills. Because of this, it’s hard for parents to tell whether their children are suffering from Type 1 diabetes, especially since the symptoms are so easy to miss—being very hungry and very thirsty are easily noticeable signs but these are also just normal behaviours of growing children and shouldn’t be a cause for alarm. 

The following are some behaviours observed in children with Type 1 diabetes:

  • Getting yeast infections (thrush).  
  • Acting out of character. Being moody or restless. Having mood swings. 
  • Losing weight despite having frequent meals.
  • Feeling tired, dull, and lacking the strength to play.
  • Peeing more, or even wetting themselves despite having been toilet trained.
  • Having a sweet-smelling breath

If while watching their children grow, parents notice any of these symptoms of elevated blood glucose levels in their infants, toddlers, or young children they should immediately seek their pediatrician’s guidance.

Type 1 diabetes can strike at any age. The sudden pause in Insulin production leads to a rapid rise in glucose levels which can quickly become Diabetic Ketoacidosis (DKA). Catching these signs early can ensure that insulin is given promptly and the quality of life is preserved. 


When to See a Doctor

The symptoms of diabetes in the early stages can easily be confused as a minor illness, so it can be hard to pinpoint exactly whether you or someone you care about, has it. But that’s okay.

If you want to confirm whether what you have been experiencing could have been diabetes, you can ask yourself these questions:

  • After getting a cold or the flu. Do you recover quickly? Do you still feel sick?
  • Have you noticed any cuts and grazes that seem to be taking longer than usual to heal?  
  • Do you experience numbness and tingling in your hands or feet? Is this a recent development or a long-term condition?
  • Have you always wrestled with yeast infections, or are recurring infections a new struggle?
  • Have you noticed weight loss you can’t explain? Are you overweight?
  • Have you felt thirstier, or found yourself drinking more than usual in recent weeks or months?
  • Have you noticed any changes in your vision?


Catching It Early Makes All The Difference

If you are concerned about your health, visit your physician and tell them your concerns. A simple test strip or lab draw can supply you both with a wealth of information about if necessary, treatment can be started. Early diagnosis and treatment by a professional make all the difference between managing your condition and having to suffer unknowingly.

Since 2012, our goal at mySugr has always been to make diabetes suck less for people within the diabetes community.  We have long endeavored to educate, advocate, and elevate the global working knowledge of living life with both type 1 and type 2 diabetes to the fullest. Utilizing our combination approach of sound coaching and advancing tech, we’ve made huge strides at creating an environment that lets all people with diabetes maintain optimum health while living their best lives!


Diabetic And Unaware

According to the World Health Organization (WHO), the number of people with diabetes rose from 108 million in 1980 to 422 million in 2014—”About 422 million people worldwide have diabetes, the majority living in low-and middle-income countries, and 1.6 million deaths are directly attributed to diabetes each year.”

According to the American Diabetes Association, in 2018, 10.5% (34.2 million American adults) of the American population had diabetes. 24.8 million were diagnosed and 7.3 million were undiagnosed. And 1.5 million Americans are diagnosed with diabetes every year.

This means that right now millions of people walking around with a dangerously high amount of glucose in your blood, experiencing complications, and receiving no treatment for them. We hope that everyone reading this gains an understanding of diabetes, whether they have it or not.

We know that it is improbable to reach everyone, but if you can help spread awareness and educate those around you on the symptoms of early-stage diabetes, that means an increased awareness in your community, which can reduce the number of undiagnosed diabetic patients in your direct environment.

If you have a family member or relative who has been diagnosed as being diabetic, to be on the safer side, you should visit your doctor to discuss the possibility of being at risk. A bi-annual blood test can provide a constant baseline for your doctor to monitor for any unusual increase in blood sugar levels. 


Dr. Babajide Ogunlana

If you or your child struggle to maintain a healthy weight, ask your doctor and/or your child’s pediatrician for pre-screening and lab work to look out for early signs of diabetes. By working hand in hand to achieve optimum health, you and your medical team can be proactive partners in warding off any symptoms of diabetes before they begin to damage peripheral systems.

If you or your child have other genetic factors (such as other auto-immune conditions), you should ask your doctor for pre-screening lab work to rule out any signs of diabetes. Auto-immune conditions tend to breed additional auto-immune conditions. Still, by creating a teamwork approach to full-body care, you can provide a protective screening system that stands sentry against the early warning signs of diabetes. In this way, you can begin any treatment at the earliest possible opportunity and set the stage for successful long-term health.




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
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). 


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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