Search

Diabetic foot syndrome (DFS) is a complex disease. The best outcomes are reported with the multi-disciplinary team (MDT) approach, where each member works collaboratively according to his/her expertise. However, which health provider should act as the team leader (TL) has not been determined. The TL should be familiar with the management of diabetes, related complications and comorbidities. He/she should be able to diagnose and manage foot infections, including prompt surgical treatment of local lesions, such as abscesses or phlegmons, in an emergent way in the first meeting with the patient. According to the Organization for Economic Co-operation and Development (OECD) reports, Italy is one of countries with a low amputation rate in diabetic patients. Many factors might have contributed to this result, including 1)the special attention directed to diabetes by the public health system, which has defined diabetes as a "protected disease", and accordingly, offers diabetic patients, at no charge, the best specialist care, including specific devices, and 2)the presence of a network of diabetic foot (DF) clinics managed by diabetologists with medical and surgical expertise. The health care providers all share a "patient centred model" of care, for which they use their internal medicine background and skills in podiatric surgery to manage acute or chronic needs in a timely manner. Therefore, according to Italian experiences, which are fully reported in this document, we believe that only a skilled diabetologist/endocrinologist should act as a TL. Courses and university master's degree programmes focused on DF should guarantee specific training for physicians to become a TL.

Aim To define the outcomes of persons with diabetes and foot ulcers (DFUs) managed through a specific triage pathway during the COVID-19 crisis. Methods Patients who had an active DFU during the COVID-19 emergency were included. All participants were managed using a specific triage system driven both by ulcer’severity and concomitant co-diseases. Subjects with severely complicated DFUs were urgently referred to hospital regardless of the concomitant comorbidities. Subjects with complicated DFUs received outpatient evaluation (within 48–72 h) and were admitted to hospital if required (revascularization, surgical intervention, intravenous antibiotic therapy); after the first outpatient visit or hospitalization, patients were followed according to the number of comorbidities (in the case of 3 or more comorbidities patients were followed up by telemedicine). Patients with uncomplicated DFUs were managed by telemedicine after outpatient evaluation. Healing, major amputation, death and rate of COVID-19 infection were evaluated. The minimum follow-up was 1 month. Results The study group included 151 patients. The mean age was 69.9 ± 14.2 years, 58.9% were male and 91.4% had type 2 diabetes; 58.7% had severely complicated, 21% complicated and 20.3% uncomplicated DFUs. Among those, 78.8% presented with 3 or more comorbidities. One hundred and six patients had regular clinical follow-ups, while 45 were managed through telemedicine. Forty-one (27.1%) patients healed, 3 (1.9%) had major amputations and 3 (1.9%) died. One patient (0.6%) reported COVID-19 positivity due to infection acquired at home. Conclusion The triage pathway adopted during the COVID-19 pandemic showed adequate management of DFUs and no cases of hospital virus exposure.

Background. The diabetic foot often undergoes abnormal plantar pressures, changing in walking strategy, ulcerative processes. The present study focuses on the effects that diabetes-induced alterations of Achilles tendon, plantar fascia and first metatarsophalangeal joint—both anatomical and functional—may have on foot loading. Methods. Sixty-one diabetic patients, with or without neuropathy, and 21 healthy volunteers were recruited. Thickness of Achilles tendon and plantar fascia was measured by ultrasound. Flexion–extension of the first metatarso-phalangeal joint was measured passively. Main biomechanic parameters of foot–floor interaction during gait were acquired and related to the above measurements. Findings. Plantar fascia and Achilles tendon were significantly (P < 0.05) thicker in diabetics than in controls; mean values (SD) for controls, diabetics without and with neuropathy were 2.0 mm (0.5), 2.9 mm (1.2) and 3.0 mm (0.8) for plantar fascia, respectively, and 4.0 mm (0.5), 4.6 mm (1.0) and 4.9 mm (1.7) for Achilles tendon, respectively. Flexion–extension of the first metatarso-phalangeal joint was significantly (P < 0.05) smaller in diabetics than in controls; mean values (SD) for controls, diabetics without and with neuropathy were 100.0 (10.0), 54.0 (29.4) and 54.9 (17.2), respectively. The increase in the vertical force under the metatarsals was strongly related (R = 0.83, explained variance = 70.1%) to the changes in the three above parameters. Interpretation. Thickening of plantar fascia and Achilles tendon in diabetics, more evident in the presence of neuropathy, concurs to develop a rigid foot, which poorly absorbs shock during landing (performs the physiological impact force absorption during landing). More generally, an overall alteration of the foot–ankle complex motion likely occurs throughout the whole gait cycle, which partly explains the abnormal loading under the forefoot. 2005 Elsevier Ltd. All rights reserved.

To evaluate the effect of local anesthesia on the skin vasodilation induced by the iontophoresis of sodium nitroprusside and heating.Skin vascular reactivity, in response to iontophoresis of sodium nitroprusside (SNP), was evaluated at the forearm and foot in 13 neuropathic diabetic (DN) and 11 nonneuropathic diabetic (D) patients and 9 healthy, nondiabetic subjects who served as controls (C). The direct (DI) and nerve axon reflex-related (N-V) vasodilation were measured by using two single-point laser Doppler probes. The vasodilation in response to local warming was also assessed. A topical anesthetic was applied on the contralateral forearm and foot and all the measurements were repeated.Dermal anesthesia resulted in a reduction of the direct vasodilation to SNP at the forearm [C: 58.1 +/- 16, D: 60.6 +/- 11%, and DN: 48.3 +/- 37% (postanesthesia percentage of reduction; mean +/- SEM), P0.01] and at the foot in all three groups (D: 38.5 +/- 12%, P0.01; C: 27.2 +/- 14% and DN: 11.3 +/- 17.5%, P=NS). The N-V related vasodilation was very low before and did not change after local anesthesia. The postanesthesia hyperemic response to warming was significantly reduced at low temperatures but did not change at 44 degrees C.The sodium nitroprusside-related vasodilation is reduced after local anesthesia in a similar way in healthy subjects and diabetic patients with and without neuropathy. The response to heating is also reduced at low temperatures. This indicates a stabilizing effect of local anesthesia on the smooth muscle cell.

Objectives. The role of tangential stress in neuropathic foot ulceration is yet unknown. The aim of this study was to investigate the tangential forces developed during gait by the whole foot and by selected subareas of it, namely the heel, the metatarsals and the hallux. Methods. 61 diabetic patients have been evaluated: 27 without neuropathy, 19 with neuropathy and 15 with previous neuropathic ulcer. The patients were compared with 21 healthy volunteers. A piezo-dynamometric platform was used to measure the three components of the ground reaction force under the total foot and the selected subareas. Results. A significant reduction was observed for the forward peak and the backward peak of the anteroposterior ground reaction force component measured under the whole foot. Patients with previous neuropathic ulcer showed a significant increase of the mediolateral stress under the metatarsals. Conclusions. Tangential stress is altered in diabetic neuropathic patients; the increased mediolateral component suggests that tangential stress could have a role in the high risk of recurrence observed in patients with previous ulceration. Relevance To assess the effectiveness of a non-invasive methodology for the estimation and the monitoring of significant alterations of the tangential stress with the increase of neuropathy.

Introduction: To accurately evaluate the extent of diabetics gait deviations from normal gait, it is important to consider not only how each feature of the gait pattern has changed but also how the relationship between the features changed. In order to improve diabetic foot prevention treatments it is important to establish the correlation that exists between gait variables and foot biomechanics alterations. Least but not less important, the large amount of variables obtained in kinematics–kinetics and plantar pressure (PP) analysis need to be reduced in order to be clinically useful. Thus, in the light of these premises, the aims of this study will be to apply cluster analysis either to agglomerate the patients with common gait deviations in the same cluster or to find which gait parameters characterizes the pathology. So far patients can be classified relatively to their gait pattern alterations and specific prevention protocols developed. Methods: Kinematics, kinetics and PP data of 35 subjects (14 normal (C), 9 diabetics (D), 12 diabetic neuropathics (DN)) have been collected by means of 6 cameras BTS Sr.l. motion capture system (60–120 Hz) synchronized with 2 Bertec force plates (FP4060-10) and 2 plantar pressure plates (Imago). A 3D foot markerset was used and gait and posture analysis performed [1]. Five homogeneous groups were created, in order to compare subjects with the same type of foot: cavus foot (CF), CF and valgus (V) heel, CF and normal heel, CF and normal hallux, CF and V hallux. 3D subsegments forces, plantar pressure, contact surface and joint rotation angles were calculated [1] and each group normative bands (nb) created (mean � 1SD). COP pattern was analyzed in both