Footnote December 2017

footnote THE NEWSLETTER • December 2017

From the AFR Region

Step-by-Step course in Nigeria From the MENA Region

Footwear project in Pakistan Congresses

Diabetic foot events in Porto and Venice Picture quiz

To tease your clinical brain Paper trail

Recent diabetic foot publications And more …

Like most of you, I expect, as we approach the festive season and a fast looming New Year, I am wondering where has the last year gone! Maybe it’s my age but the pace of life just seems to be faster with each passing year. Thinking about this, of course makes me reflect on not just the past year but achievements, challenges, hurdles and changes in recent ones. I want to share one thing that has perhaps struck me more than anything else this year regarding my ability to treat those suffering with diabetic foot ulceration.

I try to keep up to date with current research and findings, which is part of the reason why there is a PubMed abstract section to the newsletter. Anyway, I came across one published research paper that stopped me in my tracks. It was not related to any new “whizzo” technology,

EDITOR’S NOTE Neil Baker

but was very simple, yet very profound and provides challenging implementation issues. The study was conducted in Israel

by Rachel Natovich and her group looking at the cognitive function in neuropathic patients with and without foot ulceration.

In essence, this study showed very clearly that cognitive function was very impaired in the ulcer group. Although there are few robust studies, we are all convinced that ulcer patients are the least compliant and education should be but is not very effective. This paper gives us clear clues now as to why. More importantly, it raises new issues about how to approach health education to this group.

do you teach someone with learning difficulties? I have tried very recently to use learning by fun-related play in order to instil some basic concepts of offloading. I am not sure yet whether this will work … in part because I work in the Gulf and do not speak Arabic!

I think we need to rethink our health education approach and methods.

Adopting teaching methods for those who cannot learn is perhaps a starting, i.e. how

My very best wishes for Christmas and 2018.

So, as we draw to the end of another year perhaps I can challenge you to think about looking at foot health education in those with neuropathic foot ulceration from a completely different viewpoint. Try asking yourself how do I use education in those who find it almost impossible to retain and process information.

Neil

CONTENT Welcome to the December edition of “Footnote”.

For those of you around the world who celebrate Christmas may I, on behalf of all of the D-Foot International Board, wish you all a very Happy Christmas. We hope you will have a great time with whom you share this festive season. We also hope that you are looking forward to the start of a New year and hope it is a happy, healthy and successful 2018 for you all.

In this edition of the Newsletter we have some interesting news and evidence of people’s outstanding work from around the world. Please read the sections to see what your colleagues have been doing.

Additionally, we have the regular features, including Andy Myers’ commentaries on several recently published papers, the Pub-med abstract section and, of course, the clinical picture quiz.

We are looking to incorporate a few new things in the next year. Of course, “Footnote” is a vehicle to keep you all updated on important diabetic foot events from around the world. However, the editorial board of “Footnote” would welcome any feedback from readers to help us make it as current, relevant and helpful for you all as possible.

We hope you enjoy reading this edition of Footnote.

Report from the recent Diabetic Foot Study Group conference in Porto Step-by-Step training course in Nigeria Paper commentaries News from Iran Report from the Association of Diabetic Foot Surgeons meeting in Venice Footwear Project from Pakistan New President-Elect of IDF PubMed abstract Picture quiz UK Royalty aware of diabetic foot complications

DIABETIC FOOT STUDY GROUP (DFSG) Porto, 8-10 September 2017

The beautiful city of Porto welcomed 312 participants from 40 countries who attended the 14th Scientific Meeting of the Diabetic Foot Study Group (DSFG) of the European Association of the Study of Diabetes (EASD) in September this year.

Over 3 days, lively discussions were centred on all aspects of the diabetic foot and topics included Care and Quality of Life, Charcot’s foot, Diagnostics, Epidemiology, Infection, Microbiology, Offloading and Biomechanics, Prevention and Recurrence, Research and Outcome, Vascular and Orthopaedic Surgery.

The three best oral abstracts were presented on Saturday 9th September 2017. At this prize session: •

•

•

Richard Paisey from United Kingdom presented how the introduction of validated commissioning criteria in their region led to a significant reduction of diabetes related amputations.

Marco Meloni from Italy reported on the impact of below-the-ankle peripheral arterial disease on the outcomes of diabetic patients with ischemic foot ulcers (winner of 1st prize oral presentation).

Michal Dubsky from Czech Republic presented 10-year follow-up data on the recurrence of diabetic foot ulcers in a cohort of patients recruited from their centre in the Eurodiale study.

— Marco Meloni, Italy, recipient of the 1st 5me presenter travel grant

Poster prize winners were chosen from the posters in the session “Top 10 poster abstracts”.

1st prize was Sofia Antoniou from Germany who presented data from a retrospective study on time sequence of bone marrow oedema resolution in the active diabetic Charcot foot.

2nd prize winner was Timothy Jemmott from UK who reported that 60% reduction of ulcer area at two weeks predicts

— Jarmila Jirkovska, Czech Republic, the recipient of the Paul Wilson Brand Repetitive Stress Award of 2017, with the Chairmen of this prize presentation session Klaus Kirketerp-Moeller and Alberto Piaggessi.

diabetic foot ulcer healing at twelve weeks.

This year’s nominee for The Paul Wilson Brand Repetitive Stress Award was Jarmila Jirkovska from Czech Republic who researched how effectively patients with diabetic foot offload at home (picture 2).

José Luis Lázaro, Spain, (“Analysis of the foot’s morpho-functional characteristics that can predispose in the development of a Charcot’s Diabetic- Neuropathic-OsteoArthropathy”) and Ioanna Eleftheriadou, Greece, (“Bone immunohistochemistry and levels of RANKL, osteoprotegerin and inflammatory cytokines in acute charcot foot”) reported the progress of their studies supported by DFSG grants at an

— 1st time presenter travel grant recipients

invited talk session. At this session, the floor was also presented to Kristien Van Acker who informed DFSG about the activities of D-Foot International.

All the excitement escalated at the Conference dinner which took place at Palácio da Bolsa, Porto where all prize winners were announced and prizes were presented by the Chairman of DFSG, Klaus Kirketerp-Moeller from Denmark.

DFSG Life Time Achievement Award A well-kept secret of the nominee for this year’s DFSG Life Time Achievement Award was announced by Nina Petrova who presented on behalf of DFSG Committee the award to Kristien van Acker, Belguim, for her tireless global contribution of implementation of diabetic footcare.

— Kris5en van Acker, Belgium, the recipient of the 2017 DFSG Life Time Achievement Award, pictured together with Klaus Kirketerp-Moeller and Nina Petrova

STEP-BY-STEP COURSE FOR DIABETES FOOTCARE IN NIGERIA 9-11 October 2017

Felecia Anumah, Zulfiqarali G. Abbas Diabetes mellitus has become a pandemic and this inevitably will lead to an increase in the number of diabetic foot problems. The disease is silent until the onset of its’ complications with those related to the Diabetic Foot having the highest socio-economic costs.

In Nigeria, diabetes care is being carried out in primary and secondary healthcare settings where many of the healthcare providers have little/no training in foot care education or related clinical skills. Thus, patients with foot problems –foot ulceration/ infection present late to tertiary healthcare facilities. This means that in approximately 50% of the time, the only clinical option for treatment is amputation.

The Step by Step Training course aims •

to improve healthcare providers’ capacity to offer quality foot care education to persons with diabetes to prevent diabetic foot.

•

to provide basic Podiatry skills and training to empower the participants to manage common diabetes foot problems.

•

to deliver the basic and advanced sections of the course over a 2-year period.

Felecia Anumah giving a lecture

As Podiatry is not available in Nigeria we organised a Lecture series / Public Lecture on “Overview of Podiatric Medicine” on 10thOctober 2017 at University of Abuja. This was chaired by the Provost, College of Health Sciences, University of Abuja, Prof Kareem Airede.

Group photo of delegates, faculty, dignitaries and the Minister of Health -Nigeria

Dr. Abbas hands-on practice at the clinical skills training.

The Faculty members

Twenty-two (22) government healthcare facilities were selected from the Federal Capital Territory (FCT) consisting of 12 secondary FCT facilities, 7 Federal government facilities and 3 primary healthcare centres. A total of 70 healthcare providers (50 doctors and 20 nurses) were selected to attend).

The SBS training course consisted of a 3day basic course, after which the participants returned their centres implement their training. After one year, participants will return for 3 days advanced training, with supervision in this 2-year period.

The basic training course took place in Abuja Nigeria 9–11 October 2017. It was opened by the Honourable Minister of Health ably assisted by the Director of Public Health, Dr. Evelyn Ngige.

There were 5 International Faculty members including: 2 Endocrinologists: Dr Zulfiqarali Abbas (Tanzania), and Dr Elizabeth Uchegbu (UK) 3 Podiatrists: Dr Andrew Clarke (South Africa), Sarah-May Poppleton ( UK), Dr Babajide Ogunlana (USA).

The local Faculty included: Prof Anumah, Dr UkamakaItanyi -College of Health Sciences University of Abuja Dr Okudo, President, Nigerian Association of Dermatologists.

t c a r t s b A n a c S

Click on the title to go to the full abstract

A qualitative study of the experience of lower extremity wounds and amputations among people with diabetes in Philadelphia.

Barg FK, Cronholm PF, Easley EE, Davis T, Hampton M, Malay DS, Donohue C, Song J, Thom SR, Margolis DJ. Wound Repair Regen. 2017 Dec 8. doi: 10.1111/wrr.12593. [Epub ahead of print] PMID: 29220878




These study authors performed semi-structured, open-ended interviews with patients having complications from diabetes including ulceration and/or lower extremity amputation in an attempt to elucidate qualityof-life information. Interesting findings derived from these interviews revealed limited understanding of the disease process, fear of amputation, and challenges with compliance of daily wound care.

Although several studies have recently examined quality-of-life patientcentered outcomes, this investigation is unique in the open-ended nature of the patient interview/examination. This information is of substantial value to physicians with respect to the patient education process.

Mobile phone generated vibrations used to detect diabetic peripheral neuropathy.

May JD, Morris MWJ. Foot Ankle Surg. 2017 Dec;23(4):281-284. doi: 10.1016/j.fas.

2016.08.004. Epub 2016 Aug 21.

PMID: 29202988 This article describes a novel and relatively technologically advanced technique for the performance of sensorimotor neuropathy assessment in the foot with diabetes. The authors have developed a freely available mobile phone application allowing for a controlled vibratory examination. The vibrating mobile phone was tested on the index finger, patella, lateral malleolus, medial malleolus, heel, first metatarsal head and fifth metatarsal, and compared favorably to a 10g SemmesWeinstein monofilament and 128Hz tuning fork with respect to diagnostic accuracy. Although most physicians working with the diabetic foot would be expected to have monofilaments readily available, everyone seems to carry a mobile phone at all times! This might be another useful screening tool available with the monofilament, Michagin neuropathy screening instrument and Ipswich touch test.

Unplanned 30-day readmission in patients with diabetic foot wounds treated in a multidisciplinary setting.

Holscher CM, Hicks CW, Canner JK, Sherman RL, Malas MB, Black JH 3rd, Mathioudakis N, Abularrage CJ. J Vasc Surg. 2017 Oct 7. pii: S0741-5214(17)32080-3. doi: 10.1016/ j.jvs.2017.07.131. [Epub ahead of print] PMID: 29017807 Unplanned 30-day readmissions are an important performance and quality marker at many hospitals. This investigation sought to determine predictors for unplanned readmission in subjects originally admitted with a diabetic foot ulceration at an urban tertiary care center.

The overall readmission rate was 21.5% and the most common reason for readmission was worsening of a foot wound. Factors found to be associated with readmission were the presence of hypertension and/or peripheral arterial disease, a history of tobacco use, and the performance of an open vascular procedure. This information should be used as a guide for other health-care facilities to examine their own practices and determine which factors might be modified to decrease unplanned readmission rates.

The impact of glycaemic variability on wound healing in the diabetic foot - A retrospective study of new ulcers presenting to a specialist multidisciplinary foot clinic.

Dhatariya KK, Li Ping Wah-Pun Sin E, Cheng JOS, Li FYN, Yue AWY, Gooday C, Nunney I. Diabetes Res Clin Pract. 2017 Oct 31;135:23-29. doi: 10.1016/ j.diabres.2017.10.022. [Epub ahead of print] PMID: 29097286 This article adds to the body of knowledge with respect to the association between glycemic control and wound healing. Although it seems clear that there is some association between two based on clinical experience and some evidence, the specific correlation remains somewhat unclear. This article contributes to this discussion by evaluating two groups of patients with wounds: those with low HbA1c and low variability and those with high HbA1c and high variability. As one might expect, those with lower values and variability tended to heal faster and time to healing seemed to be most effected by the mean HbA1c (as opposed to variability).

Comparative cost and clinical effectiveness of clostridial collagenase ointment for chronic dermal ulcers.

Waycaster C, Carter MJ, Gilligan AM, Mearns ES, Fife CE, Milne CT. J Comp Eff Res. 2017 Oct 27. doi: 10.2217/cer-2017-0066. [Epub ahead of print] PMID: 29076747 This article provides a good example of a review of comparative effectiveness research where an intervention is not compared to a placebo, but instead to a real-world alternative. Although comparison to a placebo holds considerable value with respect to an evidence-based medicine paradigm, it is not really compatible with clinical practice.

Instead practitioners are most often tasked with deciding between two similar interventions; in this case between differing topical agents for chronic wounds. This article identifies positive effects of collagenase in comparison to other topical agents with respect to clinical effectiveness and cost effectiveness, but results should still be interpreted with some caution as reviews of this sort are dependent on the available published literature. In other words, a critical reader should still ask the question: Is collagenase more effective, or just more studied than other agents?

Unplanned 30-day readmission in patients with diabetic foot wounds treated in a multidisciplinary setting.

Holscher CM, Hicks CW, Canner JK, Sherman RL, Malas MB, Black JH 3rd, Mathioudakis N, Abularrage CJ. J Vasc Surg. 2017 Oct 7. pii: S0741-5214(17)32080-3. doi: 10.1016/ j.jvs.2017.07.131. [Epub ahead of print] PMID: 29017807 Unplanned 30-day readmissions are an important performance and quality marker at many hospitals. This investigation sought to determine predictors for unplanned readmission in subjects originally admitted with a diabetic foot ulceration at an urban tertiary care center.

The overall readmission rate was 21.5% and the most common reason for readmission was worsening of a foot wound. Factors found to be associated with readmission were the presence of hypertension and/or peripheral arterial disease, a history of tobacco use, and the performance of an open vascular procedure. This information should be used as a guide for other health-care facilities to examine their own practices and determine which factors might be modified to decrease unplanned readmission rates.

Appointment of Professor Andrew JM Boulton as President-Elect of the International Diabetes Federation Abu Dhabi, UAE, December 2017

At the recent World Diabetes meeting, elections were held for the new Board of Directors of the IDF. There were four candidates for President-Elect and at the General Assembly, Andrew Boulton was elected to this position.

He will serve as President-Elect and a member of the Board of Directors of

IDF for the next two years until the next World Diabetes meeting which will be held in South Korea in late 2019. For the next two years he will be President of IDF. Andrew Boulton has worked and researched in the areas of diabetic

neuropathy and diabetic foot disease for almost 40 years: earlier this year he gave the Banting Memorial Lecture of Diabetes UK which was entitled, “The diabetic foot: a 40 year journey”.

Together with Henry Connor, Andrew was the founder of the biennial Malvern Diabetic Foot meetings, the first one of which was held in May 1986. The next meeting will be held in Malvern, UK on 16-18 May, 2018 (www.malverndiabeticfoot.org). He has published more than 500 papers on diabetic complications and was the first awardee of the International Diabetic Foot Award at the International Diabetic Foot meeting in Noordwijkerhout, the Netherlands, May 1995.

Prior to taking up his position at the IDF, Andrew has also been editor of “Diabetic Medicine”, the journal of the British Diabetic Association, 1991-1995 and a member of the BDA Grant Committee. Subsequent to that he held a number of positions at the

European Association for the Study of Diabetes (EASD) culminating in his Presidency of EASD from 2011-2015.

Andrew is dedicated to promoting good preventative care and patient education to reduce the burden of diabetic foot disease on a global basis.

He has already led teaching courses on this topic in many parts of the world including India, China, South and Central America. During his four years on the Board of Directors, Andrew hopes to be able to bring the diabetic foot international back to its natural home which should be of course associated with IDF. A number of challenges lie ahead but with his interest in reducing the burden of diabetic foot disease in patients particularly those in low income countries, he will ensure that the foot is not neglected by the IDF during the next four years.

IRAN WORKING GROUP ON

The nuclear diabetic foot team

Endocrinology and Metabolism Research Institute (EMRI) affiliated to Tehran University of Medical Sciences was assigned as a WHO Collaborating Center for Research & Education on Management of Diabetes. The Diabetic Foot Research Group (DFRG) is a multi-disciplinary group of researchers with special interest in the diabetic foot affiliated to Diabetes Research Center. This group was available via http://emri.tums.ac.ir/dmfoot The main goal of DFRG is to enhance the knowledge and quality of practice of healthcare providers in the field of diabetic footcare through various programs such as Iranian Diabetic Foot Research Network. The main approach of this network was using a multidisciplinary team (Iran Working Group on Diabetic Foot) in diabetic foot prevention and care.

All treatment, research and professional education conducted in different setting of fully-equipped diabetic foot clinics, diabetes and endocrine wards under the supervision of endocrinologist, vascular surgeon, practitioner, infection specialist and trained nurses.

DIABETIC FOOT AT A GLANCE PROMINENT ACTIVITIES According to the main goal of DFRG comprehensive, multifaceted, and team-based training workshops and courses were hold from 2014 to now focused on topics related to diabetic foot which endorsed by the International Diabetes Federation (IDF) 2014-2016 and the European Wound Management Association (EWMA)2016-2019. Up to now about 500 nurses and general practitioners have been trained in national level.

We also cooperate with International Working Group on the Diabetic Foot (IWGDF) Guidance 2015 to translate it to Persian language and also accordingly, establish national study to adapt/ adopt of clinical practice guideline on management of diabetic foot for local use in Iran. Moreover, extensive areas of research currently have been investigated in novel treatment such as NPWT, Larval therapy, Plasma medicine and other related topics.

DFRG attempts to leads the fight against the consequences of diabetes particularly of DF to improve patients’ outcome.

Translated IWDGF Guidance document

THE ASSOCIATION OF DIABETIC FOOT SURGEONS (ADFS) This is an international not-for–profit organization for surgeons working with the diabetic foot syndrome. It was established in 2014 for supporting cooperation and best practice in research, education and clinical interventions between foot surgeons working in diabetic foot field. To expand and facilitate this we also have a very close partnership and collaborative working relationship with D-Foot International.

The aim of ADFS is to create a professional forum for different groups of specialists doing diabetic foot surgery throughout the world.

With this goal in mind we cooperate with and support contact to other associations. We organize conferences and meetings to promote the sharing of knowledge and experiences about surgery on the diabetic foot. One of our principal objectives is to promote knowledge, exchange experience, establish guidelines and train surgeons from countries worldwide.

We are aware that the surgical treatment/management of diabetic foot complications is one of the less known issues in this field. Creating an evidence base, sharing surgical practices worldwide will facilitate the formation of a global net of diabetic foot surgeons. Surgical diabetologists, orthopaedic, vascular, plastic and general surgeons, podiatric surgeons and any specialist involved in diabetic foot surgery will have a place in our association From November 9th to 11th we organized in Venice the 3rd Conference of the Association.

About 300 participants from 30 nations attended the meeting and shared experiences about surgical hot topics. Live sessions with the most important surgical procedures commented by key opinion leaders were very appreciated.

The new Board Bouncil was elected: Luca Dalla Paola (Italy) Armin Koller (Germany) Thomas Zgonis (USA) Klaus Kirketerp-Moeller (Denmark) Alberto Piaggesi (Italy) Dane K Wukich (USA) Robert G Frykberg (USA) Arun B Bal (India) Javier Aragon Sanchez (Spain) Venu Kavarthapu (UK)

President Immediate Past President Scientific Officer Secretary Treasurer Board Member Board Member Board Member Board Member Board Member

FOOTWEAR FOR EVERY PERSON WITH DIABETES The footwear initiative in Pakistan

Footwear training class

Footwear pattern cutting

Training about incorporating pressure relief in sandals

DURABLE FOOTWEAR

SUBSEQUENT TRAINING COURSE

The footcare team at Baqai Institute of Diabetology and Endocrinology, Karachi, Pakistan, developed the concept of standardized, low cost and durable footwear for people with diabetes.

Subsequently, a project proposal based on that concept was designed and submitted to WDF, which was approved as the project “Footwear for Every Diabetic”

A practical training manual was printed in the national language of Pakistan.

Initiation of this project in Pakistan is an important landmark in prevention of foot ulcers and improving the diabetic foot care.

The footwear manufacturing network includes the main project center at Karachi and peripheral project centers, across the country.

TRAIN-THE-TRAINER PROGRAMME Ten foot care assistants and 10 footwear technicians from the main project center were trained intensively in the footwear manufacturing techniques, by Mr Bent R. Nielsen, the Master Trainer.

From each of the peripheral project centers, a team consisting of a foot care assistant and a footwear technician were trained. The course was conducted by the team already trained in “Train-the-Trainer Programme”.

RISK ASSESSMENT CLINICS At risk assessment clinics established at the main project center and peripheral project centers, People with diabetes are being regularly examined and the risk categories identified. Subsequently they are referred to the footwear department for counseling, advising and manufacturing the standardized footwear according to the risk category.

AWARENESS LITERATURE An educational booklet on foot care and footwear, compiled in the national language is being distributed at risk assessment clinics.

Shoe stitching training

Finished sandal

THE PROJECT SOFTWARE The project software has been developed and is being used to collect the data.

During the initial six months: In addition to the main project center, four peripheral project centers with footwear manufacturing facilities have been established. Over 15,000 people with diabetes have been examined for diabetic foot problems and educated on foot care and footwear, among which nearly 9500 (61.08%) are identified as having feet at risk. More than 3100 pairs of standardised low cost and durable footwear have been manufactured. The footwear is gradually becoming more and more acceptable for people with diabetes.

On the 16th of November this year Neil Baker our Editor in Chief was presented with a UK national award – Order of the British Empire – OBE, for his outstanding services to Diabetes and Podiatry.

The award ceremony took place at Buckingham Palace and the medal was presented by His Royal Highness Prince Charles.

Although this may be interesting, the conversation between Neil and his Royal Highness is more noteworthy. Neil assumed that any conversation whilst being presented with the award would follow the lines of pleasantries. For example: ”Did it take you long to get here, Norfolk is a lovely County, isn’t it?“(the royal family have a large residence there that they frequently use – Sandringham Castle), etc.

But the conversation was very different indeed. His Royal Highness mentioned that he was aware that the focus of Neil’s work was diabetic foot complications and these could be very unpleasant and challenging. Additionally, and more surprisingly he commented he understood that many of these complications could be prevented!! Due to the course of this conversation Neil was able to inform his Highness that every 20 seconds a lower limb is amputated due to diabetes worldwide, this he was unaware of.

This was very special and memorable day for Neil and his family not just because of the honour of receiving such an award but also to be able to have the opportunity to speak to the future King of Britain about the plight of diabetic foot sufferers worldwide.

DIAFI TOOL OF D-FOOT INTERNATIONAL “Measuring is knowing”

Over the last four years, in cooperation with Line Klinebreil, from University Numérique Mondiale Francophone (UNMF) we have developed a diabetic foot data collection tool called “DIAFI” to facilitate the recording and analysis of simple standardised information regarding diabetic foot parameters including screening, disease states, interventions and outcomes. The tool is especially developed for low and middleincome regions and for intermediate or basic care levels.

We would direct you to our website for more information; please click on the DIAFI logo.

We would like to share with you how DIAFI is being successfully used in Sofia Bulgaria and about our future plans.

DIAFI IN BULGARIA We are routinely using the DIAFI- DATA program in our clinical practice at the Department of Diabetology at the University Hospital of Endocrinology, Medical University, Sofia, Bulgaria. This is the only specialized Department of Diabetology in the country, being a

tertiary referent centre for diabetes care in Bulgaria.

Ani Todorova a PhD student is performing diabetic foot screening and risk stratification together with treating foot ulcer patients. She has entered more than 500 patients into the database so far.

“We find this program quite useful for our everyday work and we are really glad to have the opportunity to use it and to be able to follow up our patients with or even without diabetic foot”.

THE DIAFI STUDY PROJECT IN 2018 Together with William Jeffcoate, Fran Game and the DFI-DIAFI working group, including the UNFM team we will conduct a clinical study with users of the DIAFItool from the 7 world regions. The aim is to collect and analyse data from these regions, furthermore to determine its ease of use and implementation as a data collection tool. We have high expectations of this initiative and hope that the outcome of this work will be the start of a bigger initiative: a global diabetes atlas.

Dr. Javier Aragón-Sánchez MD, PhD was the recipient of the 7th Annual Paul Brand Memorial Lecture Award at the Desert Foot Meeting in Phoenix, AZ, 30th day of November, 2017.

Dr. Aragón-Sánchez received the award from Prof.

Robert Frykberg. The title of his lecture was “The diabetic foot infections: lessons from a Spanish Surgeon”.

The main research field of Dr. Aragón-Sánchez is the surgical treatment of infections, specially osteomyelitis, in the feet of people with diabetes.

He is the author of three textbooks and more than 20 chapters in other textbooks dealing with diabetic foot problems.

He is the author of more than 70 peer-review papers. He is member of the Board of the IWGDF Infections Group and member of the Board of the Association of Diabetic Foot Surgeons. He has been collaborating in low-income countries in LatinAmerica training surgeons in limb salvage procedures and implementing research groups to increase the knowledge of diabetic foot disease in that countries.

Assisting to reduce the number of diabetic-related amputations in developing countries is one of the projects in which Dr. Aragón-Sánchez is currently involved.

Q ui z CLINICAL PICTURE QUIZ I hope you enjoyed the “foot print” quiz in the last edition of Footnotes, of course all of the clinical picture quizzes are available in the old newsletters if you missed one.

Please take a look at the photograph below. This may not appear to be very challenging and in essence it is not. However sometimes we fall prey to “not seeing the wood for the trees”. The reason for choosing the image for this quiz is that I felt it would be good to try to link it with the last one. So, try to imagine what the carbonised foot print might look like and what it could tell you.

Have fun and why not show this to your colleagues and see what they come up with. ☺ So as always … a few questions to get started….

1. List the deformities that you see 2. What else do you see?

3. What is the likely cause of the deformities?

4. Does it matter if the foot is weight-bearing when considering the deformities?

5. What are the implications of the deformities?

6. How would you manage what you see?

ANSWERS AND SUGGESTIONS 1. At first glance the lesser toe deformities may be described as clawed toes.

However, upon closer inspection it is only the 2nd toe that has a claw type deformity (i.e. the proximal phalanx is dorsiflexed, the intermediate phalanx is neutral or slightly plantar flexed and the distal phalanx is plantarflexed and weight-bearing). The 3-5th toes appear to be retracted not clawed i.e. the apices (toe tips) are not in contact with the ground. Although it is not possible to see the plantar aspect to be completely certain.

The 1st toe has a dorsiflexed proximal phalanx with a possibly slightly plantar flexed distal phalanx although it is difficult to see as there is not a side view of the toe. This deformity is termed a “trigger toe”. It is important to bear in mind that the picture we are seeing is non-weight-bearing so, there could be some changes to the above.

Other more subtle visible features include – the distal phalanx of the 1st toe has a slight laterally deviation, the 3rd and 4thdistal phalanges are slightly medially rotated and the 5th toe is medially rotated at with the metatarsophalangeal joint and or the proximal phalangeal joint.

2. The 1st toe has an apparent old subungual haematoma in the central part of the nail plate with some slight thickening of the nail plate in the ventral surface distally i.e. over the nail bed. This from the picture looks slightly friable with possible subtle erosion just lateral to the haematoma in the distal free edge.

Additionally, you can clearly see a disruption to the growth pattern evidenced by the transverse line in the proximal half of the nail plate. There is also what appears to be loose tissue attached to this transverse line, which is most likely part of the old eponychium.

4. If you look at the 5th toe it would appear to be thicker /swollen compared to the other lesser toes. This of course could be because of the angle of view; however, it would be sugges@ve of some previous or current injury. If there is an open wound (that we cannot see on the photo) it would suggest osteomyeli@s as the toe is sausage shaped. If there is no open wound then it could most likely be the result of previous osteomyeli@s or a digital fracture. From the photo you can see evidence of what appear to be a healed ulcer site over the mid-lateral surface of the toe proximal to the base of the nail. It looks as if some superficial callus has been removed to reveal this. With this observa@on I would suggest that the swollen toe is due to previous osteomyeli@s and reviewing previous x-rays would be essen@al and repea@ng if required.

5. You can also see clear prominence of the Extensor Hallucis Longus tendon and less so the Extensor Digitorum Longus tendon to the 2nd and 3rd toes. This may be early signs of developing motor neuropathy as there appears to be a liQle “hollowing out” in the distal end of the 1st and 2nd metatarsal space. Possibly indicate atrophy of the Interossei and Lumbrical muscle belly’s. However again we need to see whether this is s@ll apparent on weight -bearing to be sure.

6. The skin appears to be healthy but dry, there does not appear to be any evidence of significant peripheral arterial disease as the skin is of uniform colour and it looks healthy with normal nail growth. If PAD was present the skin colour would be darker distally, this is also true for inflamma@on although of course the distribu@on would relate to the inflamed area.

CONSIDERATIONS We are looking at the dorsal picture of the foot however we must consider plantar surface. It is always important to remember that if you see clawing, hammered or retracted toes the metatarsal inclina@on will have altered. This means that the metatarsal heads will almost certainly be in a prominent plantarflexed posi@on. The rela@onship between the rear and forefoot is cri@cal too. If there is ankle Equinus then it is likely that the forefoot may be in an inverted posi@on. This will mean that the 5th and possibly 4th metatarsal heads will be prominent and bearing a lot of force. Equally to stabilise the foot in this situa@on the 1st ray may also be plantar flexed and prominent. Thus, protec@ng these areas is paramount if ulcera@on is to be prevented.

The apices of the toes …. if they are flaQened then they are weight-bearing, if they appear rounded they are not. It is not uncommon to see a combina@on of both. Once again these are high risk areas that need protec@ve considera@on.

Removing the cause of the damaging force applied to the dorsal surface of the 5th toe is impera@ve as ulcer relapse is a real danger here.

The 1st toe nail damage warrants some ac@on. Was this a one-off trauma or repeated, if the laQer is will invariably be footwear related – shallow toe box, slip on, narrow fronted shoes.

The dry skin needs to be considered especially around the borders of the heels, so using a urea or glycerine based moisturiser would be efficacious.

The use of therapeu@c extra depth shoes would be essen@al in the on-going management of this can. Ensuring that there is adequate depth in the toe box, sufficient width to accommodate the 5th toe. Be aware that is it common in this foot type to have a narrow heel and a broad forefoot, this is problema@c in fiang shoes. This is not just from the technical side but also pa@ent acceptance as the shoes may appear like flippers!!

Managing the prominent metatarsal heads may require and total contact style or perhaps a simple flat 9mm thick cushioning insole. This will depend upon several individual factors. This may be influenced by the choice of the shoe outer sole i.e. whether it is flat or a rocker design (placement and angle need to be considered carefully).

Obviously regular inspec@on and footcare together with repeated educa@on is a given.

I hope this has been fun and informa@ve and …. Yes, I know all of this is obvious but some@mes its good to revisit the simple things. More in the next “Footnotes”.

Angiology. 2017 Jan 1:3319717695994. doi: 10.1177/0003319717695994. [Epub ahead of print] Ankle duplex scan: readily learned and accurate in diabetes.

Normahani P1, Powezka K1, Aslam M1, Standfield NJ1, Jaffer U1.

We aimed to train podiatrists to perform a focused duplex ultrasound scan (dus) of the tibial vessels at the ankle in diabetic patients; podiatry ankle (podank) duplex scan. Thirteen podiatrists underwent an intensive 3-hour long simulation training session. Participants were then assessed performing bilateral podank duplex scans of 3 diabetic patients with peripheral arterial disease. Participants were assessed using the duplex ultrasound objective structured assessment of technical skills (duosats) tool and an "imaging score". A total of 156 vessel assessments were performed. All patients had abnormal waveforms with a loss of triphasic flow. Loss of triphasic flow was accurately detected in 145 (92.9%) vessels; the correct waveform was identified in 139 (89.1%) cases. Participants achieved excellent duosats scores (median 24 [interquartile range: 23-25], max attainable score of 26) as well as "imaging scores" (8 [8-8], max attainable score of 8) indicating proficiency in technical skills. The mean time taken for each bilateral ankle assessment was 20.4 minutes (standard deviation ¹6.7). We have demonstrated that a focused dus for the purpose of vascular assessment of the diabetic foot is readily learned using intensive simulation training.


J Biol Regul Homeost Agents. 2017 Oct-Dec,;31(4 Suppl 1):141-146.

Autologous lipotransfer versus stromal vascular fraction enriched lipoinjection for diabetic foot wounds healing: a pilot study.

Vicenti G1, Solarino G1, Pesce V1, Moretti L1, Notarnicola A1, Carrozzo M1, Rifino F1, Moretti B1.

Chronic ulcers of the lower limbs represent a significant social and economic burden. Diabetes is a strong risk factor for development of chronic lesions. Adult stem cells and growth factors derived from the adipose tissue are among the most promising therapeutic strategies for hard to heal wounds. Fat grafts have been used for several decades to treat soft tissue deformities, but despite its excellent characteristics, the outcome was unpredictable, due to partial necrosis and resorption of the graft. Stem cells’ enrichment of these grafts or their injection into the edges of the ulcers have shown encouraging results in various experimental settings. In this pilot study, we compared the standard of care to autologous lipotransfer and stromal vascular fraction (svf) enriched lipoinjection in 30 patients with diabetic foot ulcers, showing clear superiority of svf enriched lipoinjection in terms of percentage of reduction of ulcers size and healing time.

Int J Low Extrem Wounds. 2017 Nov 1:1534734617737659. Doi: 10.1177/1534734617737659. [Epub Ahead Of Print] Micronutrients and natural compounds status and their effects on wound healing in the diabetic foot ulcer.

Kulprachakarn K1, Ounjaijean S2, Wungrath J3, Mani R4,5,6, Rerkasem K1,4.

The diabetic foot ulcer (dfu) is an invariably common complication of diabetes mellitus, it is also a significant cause of amputation as well as extended hospitalization. As most patients with dfu suffer from malnutrition, which has been related to improper metabolic micronutrients status, alterations can affect impaired wound healing process. Micronutrients and herbal remedies applications present a wide range of health advantages to patients with dfu. The purpose of this review is to provide current evidence on the potential effect of dietary supplementations such as vitamins a, c, d, e, magnesium, zinc, copper, iron, boron, and such naturally occurring compounds as aloe vera, naringin, and radix astragali (ra) and radix rehmanniae (rr) in the administration of lower extremity wounds, especially in dfu, and to present some insights for applications in the treatment of dfu patients in the future.

Clin Podiatr Med Surg. 2018 Jan;35(1):105-121. Doi: 10.1016/J.Cpm. 2017.08.012. Epub 2017 Oct 23.

Treating Charcot arthropathy is a challenge: explaining why my treatment algorithm has changed.

Didomenico L1, Flynn Z2, Reed M3.

Charcot deformity is a challenge that foot and ankle surgeons struggle to manage successfully. Despite the advances in knowledge, technology, and treatment modalities, limb loss is still greater than 10%. This article discusses the efficacy of conservative measures and traditional surgical approaches. It proposes a multidisciplinary team approach, medical optimization, and lifestyle modification to put the patient in the best position to heal. Also discussed is the authors' staged surgical treatment protocol to enhance outcomes and decrease the rate of limb loss.

Comput Biol Med. 2017 Dec 1;91:326-336. Doi: 10.1016/ J.Compbiomed.2017.10.030. Epub 2017 Oct 26.

Computer aided diagnosis of diabetic foot using infrared thermography: a review.

1.Adam M1, Ng EYK2, Tan JH3, Heng ML4, Tong JWK5, Acharya UR6.

Diabetes mellitus (dm) is a chronic metabolic disorder that requires regular medical care to prevent severe complications. The elevated blood glucose level affects the eyes, blood vessels, nerves, heart, and kidneys after the onset. The affected blood vessels (usually due to atherosclerosis) may lead to insufficient blood circulation particularly in the lower extremities and nerve damage (neuropathy), which can result in serious foot complications. Hence, an early detection and treatment can prevent foot complications such as ulcerations and amputations.

Clinicians often assess the diabetic foot for sensory deficits with clinical tools, and the resulting foot severity is often manually evaluated. The infrared thermography is a fast, nonintrusive and non-contact method which allows the visualization of foot plantar temperature distribution.

Several studies have proposed infrared thermography-based computer aided diagnosis (cad) methods for diabetic foot. Among them, the asymmetric temperature analysis method is more superior, as it is easy to implement, and yielded satisfactory results in most of the studies. In this paper, the diabetic foot, its pathophysiology, conventional assessments methods, infrared thermography and the different infrared thermography-based cad analysis methods are reviewed.

J Diabetes Sci Technol. 2017 Nov 1:1932296817740593. Doi: 10.1177/1932296817740593. [Epub Ahead Of Print] Analysis: a step toward standardizing diabetic foot images.

Ladyzynski P1.

In this issue of journal of diabetes science and technology yap and coauthors report on the design and present results from a reliability study of the application called footsnap that is intended for standardization of the distance and the orientation of the camera relative to the diabetic foot that is photographed. To produce standardized photographs footsnap uses a straightforward, yet original and useful method. However, other systems have been reported and clinically tested earlier, in which the same parameters of foot images might be standardized and which are free of some limitations of footsnap. Nevertheless, footsnap should contribute to increase clarity of documenting changes in the diabetic foot shape, texture color and lesions, and it should facilitate application of automatic image processing algorithms.


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