Diabetic foot secondary prevention: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Diabetic foot}} | {{Diabetic foot}} | ||
{{CMG}}; {{AE}} {{Anahita}} {{USAMA}} | |||
==Overview== | |||
For an appropriate [[Prevention (medical)|secondary prevention]], [[physicians]] should focus on strategies such as [[pressure]] offloading, use of appropriate [[foot]]wear (such as [[pressure]]-relieving [[foot]]wear), [[treatment]] of existing [[infection]] and debridement. Early [[amputation]] and reconstruction of the damaged [[Blood vessel|vessels]] could also assist faster [[wound healing]] and will prevent further destruction. | |||
==Secondary Prevention== | |||
{{See_also|Diabetic neuropathy secondary prevention}} | |||
The [[Prevention (medical)|secondary prevention]] of [[diabetic foot]] [[ulcer]] includes the following along with the use of [[Prevention (medical)|primary preventive strategies]]:<ref name="pmid28614678">{{cite journal| author=Armstrong DG, Boulton AJM, Bus SA| title=Diabetic Foot Ulcers and Their Recurrence. | journal=N Engl J Med | year= 2017 | volume= 376 | issue= 24 | pages= 2367-2375 | pmid=28614678 | doi=10.1056/NEJMra1615439 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28614678 }} </ref><ref name="pmid11280471">{{cite journal| author=Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, Kravitz S | display-authors=etal| title=Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons. | journal=J Foot Ankle Surg | year= 2000 | volume= 39 | issue= 5 Suppl | pages= S1-60 | pmid=11280471 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11280471 }} </ref><ref name="pmid11054880">{{cite journal| author=Cavanagh PR, Ulbrecht JS, Caputo GM| title=New developments in the biomechanics of the diabetic foot. | journal=Diabetes Metab Res Rev | year= 2000 | volume= 16 Suppl 1 | issue= | pages= S6-S10 | pmid=11054880 | doi=10.1002/1520-7560(200009/10)16:1+<::aid-dmrr130>3.0.co;2-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11054880 }} </ref><ref name="pmid11475459">{{cite journal| author=Hartsell HD, Fellner C, Saltzman CL| title=Pneumatic bracing and total contact casting have equivocal effects on plantar pressure relief. | journal=Foot Ankle Int | year= 2001 | volume= 22 | issue= 6 | pages= 502-6 | pmid=11475459 | doi=10.1177/107110070102200609 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11475459 }} </ref> | |||
*[[Pressure]] offloading | |||
**Elevation of the involved [[foot]] | |||
**For total [[pressure]] offloading, [[crutch|crutches]] or wheelchairs could be used. | |||
**Total contact casting (TCC) is the ideal way of [[pressure]] offloading. Nevertheless to avoid any [[Iatrogenesis|iatrogenic]] [[Complication (medicine)|complication]] it should be monitored weekly by an expert [[physician]]. | |||
**Removable walking braces and half shoes could be used as well. | |||
*Rest | |||
*Appropriate [[foot]]wear (such as [[pressure]]-relieving [[foot]]wear) | |||
*[[Prevention (medical)|Prevention]] of [[infection]] | |||
*Appropriate and complete [[infection]] [[treatment]] | |||
*Debridement | |||
*Early [[amputation]] | |||
*Reconstruction of the damaged [[Blood vessel|vessels]] | |||
===Clinical Trials=== | |||
*A major [[randomized controlled trial]] of specialized [[foot]]wear showed no benefit for [[patients]] with a prior [[foot]] [[ulcer|ulceration]] (see table below).<ref name="pmid12020336">{{cite journal| author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et al.| title=Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336 }} </ref> | |||
*A small and non-randomized trial showed the benefits of custom [[foot]]wear in [[patients]] with a prior [[foot]] [[ulcer|ulceration]], with a [[number needed to treat]] of 4 [[patients]].<ref name=pmid8721941">{{cite journal |author=Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G |title=Manufactured shoes in the prevention of diabetic foot ulcers |journal=Diabetes Care |volume=18 |issue=10 |pages=1376-8 |year=1995 |pmid=8721941}}</ref> | |||
{| class="wikitable" | |||
|+ Randomized controlled trials of interventions for secondary prevention of complications of diabetic foot<ref name="pmid8721941">{{cite journal| author=Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A | display-authors=etal| title=Manufactured shoes in the prevention of diabetic foot ulcers. | journal=Diabetes Care | year= 1995 | volume= 18 | issue= 10 | pages= 1376-8 | pmid=8721941 | doi=10.2337/diacare.18.10.1376 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8721941 }} </ref><ref name="pmid12020336">{{cite journal| author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et al.| title=Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336 }} </ref><ref name="pmid18758747">{{cite journal| author=Lincoln NB, Radford KA, Game FL, Jeffcoate WJ| title=Education for secondary prevention of foot ulcers in people with diabetes: a randomised controlled trial. | journal=Diabetologia | year= 2008 | volume= 51 | issue= 11 | pages= 1954-61 | pmid=18758747 | doi=10.1007/s00125-008-1110-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18758747 }} </ref>. | |||
! rowspan="2"|Trial!!rowspan="2"| Patients!!rowspan="2"| Intervention!!rowspan="2"|Comparison !!rowspan="2"|Outcome!!colspan="2"|Results!!rowspan="2"|Comment | |||
|-<br/> | |||
! Intervention!!Control | |||
|- | |||
| Uccioli<ref name="pmid8721941"/><br/>1995 || 69 patients<br/>• Prior [[ulcer|ulceration]]|| Therapeutic shoes||Usual [[foot]]wear|| Re-ulceration || 28%|| 58%|| Significant difference | |||
|- | |||
| Reiber<ref name="pmid12020336"/><br/>2002|| 400 patients<br/>• Prior [[ulcer|ulceration]]<br/>• Excluded severe deformity||Therapeutic shoes||Usual [[foot]]wear|| Re-ulceration || 15%|| 17%|| Insignificant difference | |||
|- | |||
| Lincoln<ref name="pmid18758747"/><br/>2008|| 172 patients<br/>• Prior ulceration<br/>• Specialist clinic|| Targeted, one-to-one education ||Usual care||Re-ulceration at<br/>• 6 months<br/>• 1 year|| • 30%<br/>• 41%||• 21%<br/>• 41%||• Insignificant<br/>• Insignificant | |||
|} | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Endocrinology]] | [[Category:Endocrinology]] | ||
[[Category: | [[Category:Up-to-date]] | ||
Latest revision as of 09:32, 30 January 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2] Usama Talib, BSc, MD [3]
Overview
For an appropriate secondary prevention, physicians should focus on strategies such as pressure offloading, use of appropriate footwear (such as pressure-relieving footwear), treatment of existing infection and debridement. Early amputation and reconstruction of the damaged vessels could also assist faster wound healing and will prevent further destruction.
Secondary Prevention
The secondary prevention of diabetic foot ulcer includes the following along with the use of primary preventive strategies:[1][2][3][4]
- Pressure offloading
- Elevation of the involved foot
- For total pressure offloading, crutches or wheelchairs could be used.
- Total contact casting (TCC) is the ideal way of pressure offloading. Nevertheless to avoid any iatrogenic complication it should be monitored weekly by an expert physician.
- Removable walking braces and half shoes could be used as well.
- Rest
- Appropriate footwear (such as pressure-relieving footwear)
- Prevention of infection
- Appropriate and complete infection treatment
- Debridement
- Early amputation
- Reconstruction of the damaged vessels
Clinical Trials
- A major randomized controlled trial of specialized footwear showed no benefit for patients with a prior foot ulceration (see table below).[5]
- A small and non-randomized trial showed the benefits of custom footwear in patients with a prior foot ulceration, with a number needed to treat of 4 patients.[6]
| Trial | Patients | Intervention | Comparison | Outcome | Results | Comment | |
|---|---|---|---|---|---|---|---|
| Intervention | Control | ||||||
| Uccioli[7] 1995 |
69 patients • Prior ulceration |
Therapeutic shoes | Usual footwear | Re-ulceration | 28% | 58% | Significant difference |
| Reiber[5] 2002 |
400 patients • Prior ulceration • Excluded severe deformity |
Therapeutic shoes | Usual footwear | Re-ulceration | 15% | 17% | Insignificant difference |
| Lincoln[8] 2008 |
172 patients • Prior ulceration • Specialist clinic |
Targeted, one-to-one education | Usual care | Re-ulceration at • 6 months • 1 year |
• 30% • 41% |
• 21% • 41% |
• Insignificant • Insignificant |
References
- ↑ Armstrong DG, Boulton AJM, Bus SA (2017). "Diabetic Foot Ulcers and Their Recurrence". N Engl J Med. 376 (24): 2367–2375. doi:10.1056/NEJMra1615439. PMID 28614678.
- ↑ Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, Kravitz S; et al. (2000). "Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons". J Foot Ankle Surg. 39 (5 Suppl): S1–60. PMID 11280471.
- ↑ Cavanagh PR, Ulbrecht JS, Caputo GM (2000). "New developments in the biomechanics of the diabetic foot". Diabetes Metab Res Rev. 16 Suppl 1: S6–S10. doi:10.1002/1520-7560(200009/10)16:1+<::aid-dmrr130>3.0.co;2-z. PMID 11054880.
- ↑ Hartsell HD, Fellner C, Saltzman CL (2001). "Pneumatic bracing and total contact casting have equivocal effects on plantar pressure relief". Foot Ankle Int. 22 (6): 502–6. doi:10.1177/107110070102200609. PMID 11475459.
- ↑ 5.0 5.1 5.2 Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C; et al. (2002). "Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial". JAMA. 287 (19): 2552–8. PMID 12020336.
- ↑ Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G (1995). "Manufactured shoes in the prevention of diabetic foot ulcers". Diabetes Care. 18 (10): 1376–8. PMID 8721941.
- ↑ 7.0 7.1 Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A; et al. (1995). "Manufactured shoes in the prevention of diabetic foot ulcers". Diabetes Care. 18 (10): 1376–8. doi:10.2337/diacare.18.10.1376. PMID 8721941.
- ↑ 8.0 8.1 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ (2008). "Education for secondary prevention of foot ulcers in people with diabetes: a randomised controlled trial". Diabetologia. 51 (11): 1954–61. doi:10.1007/s00125-008-1110-0. PMID 18758747.