footnote THE NEWSLETTER • June 2017
All in a name?
Meet D-Foot International Report from Houston Texas th 17
Global Diabetic Foot Symposium
Paper trail
Andy Meyr’s commentary Picture quiz
Another clinical brain teaser Abstract section
A literature search of recent diabetic foot publications And more …
EDITOR’S NOTE Neil Baker Dear Readers Firstly, we apologise for the long gap since the last newsletter but a lot has happened from a restructuring point of view. This newsletter was held back so that we could inform you all of the significant changes that have taken place since January. You will recall that we have already undergone some changes last year when we introduced you all to the new Chair and Board. We will no longer be called IWGDF— Implementation section but have re-branded as D-Foot International. One immediate change is that our newsletter is now housed on our new website where more information can be found about us and our activities. Therefore, the focus of this Newsletter is predominately to inform you of some of the important information regarding the organisational changes. Please take the time to read this edition of the Newsletter, it is not long on purpose. We still have a few regular topics and one conference report.
CONTENT ALL IN A NAME? D-FOOT INTERNATIONAL Organisation We are now a registered non-profit association under Belgian law. Schematic diagram of organisation This shows a simplified diagram of the structure of the organisation, its members and associate partners. Meet the Board There are now 8 Board members and a CEO. Find out more about them and who they are. Memberships explained D-Foot is composed of different types of membership. Do you qualify for membership? Governance structure This gives a very brief overview of the D-Foot International governance structure. Aim, goals and activities Find out what we are doing. REPORT FROM HOUSTON TEXAS th 17
In this section, you can read about the Global Diabetic Foot Symposium aka “DFCon” that took place at the Royal Sonesta Hotel in Houston, Texas, USA, from 23-25 March 2017. This is conference that occurs every year and although is reputed to be the showcase diabetic foot event worldwide. It is always has a full and varied programme that includes formal lectures on a wide range of topics, latest technologies, evidence and practical hands on interactive workshops and demonstrations. Read more from David Armstrong about the last conference.
COMMENTARY ON RECENT PAPERS Once again Andy Meyr, our resident scientific paper commentator, has done a great job searching through recent publications and has chosen several that he thought would be valuable to read. They include ulcer relapse, association with retinopathy and foot ulceration, laboratory markers and osteomyelitis, etc. PICTURE QUIZ We hope you enjoyed this section last time and found it fun but also thought provoking. Here’s another clinical brain teaser in the form of an X-ray and some basic background details. We will be following the same format as previously, so have a look at the X-ray, there are some questions to help formulate your thoughts and then try to decide what you would do in the immediate, short and long term. Again there are a few suggestions from the editor at the end to stimulate some thought. Have fun! ABSTRACT SECTION Welcome again to this section where I have put together a literature search of recent diabetic foot publications. I personally value this as it helps to keep me up to date with current evidence and stimulates my thoughts and clinical practice. I have posted just over 70 abstracts of recent papers I hope that you find some of them useful and interesting. Thank you for reading this edition of the Newsletter and hopefully some of the items will be have been of interest. Thank you for reading this edition of the Newsletter and hopefully some of the items will be have been of interest.
D-Foot International is a new international non-profit association established under Belgian law on 5 April 2017. The organisation is a rebranding of and continues the work of the Implementation Group of the International Working Group on the Diabetic Foot (IWGDF). So why change from IWGDF to D-Foot International? There are several reasons for this change, but here are a few of the important reasons: • We needed address our concerns regarding legal protection of the volunteer leadership of the Implementation Group as there was none. • Identity: globally there was a lot of confusion about each section of the IWGDF. Many perceived us to be the consensus or Diabetic foot symposium group or both but not purely an implementation group. Of course, we are and always have been intrinsically linked and fully supportive of these but are in essence different. D-Foot International will, in the short term, continue to carry the tagline ”International Working Group on the Diabetic Foot — Implementation”. As from now, D-Foot develops its activities separately from the International Diabetes Federation (IDF), with which organisation it has severed its legal and operational ties. D-Foot continues the work closely with the IWGDF—Guidance group to create a fruitful and reciprocal integration of implementation and guidance.
D-Foot International is composed of Full Members. Full members are diabetic foot specialists from the various professional disciplines of diabetic foot management and care, from around the world. They represent their own respective country and vote at the General Assembly. To become a Full member, individuals must first apply to the Regional Council as a Provisional member (see our 7 regions of national representatives). Applications for provisional membership are reviewed by the Board. Applicants who meet the criteria of Provisional membership will be admitted and duly informed. Provisional members have no voting rights until admitted as Full members. Provisional memberships remains in place until the next annual General Assembly when they will be adopted as Full members. In addition to Full and Provisional memberships, the D-Foot International Board of Directors consider admitting individual and institutional memberships to the organisation: Individuals members are those who make a financial contribution to the organisation as non-voting Associate Members. Institutional Members are either Associations e.g. professional bodies, etc. These will be known as “Association” Members. Commerical companies/sponsors will be known as “Corporate” Members. The organisation also has non-voting Honorary Presidents and Honorary Members. The Board will create “standing” committees. These will include: Audit and Risk Management Committee, Governance, Ethics Committee, Advisory Committee.
D-Foot International is an international non-profit association registered under Belgian law. The association is governed by Full Members, who constitute the General Assembly, and a volunteer Board of Directors. The General Assembly is composed of Delegates, these are: the Full Members and the Members of the Board. Full Members are the national representatives, representing their respective country. They are selected across all disciplines related to diabetic foot management. D-Foot International is composed of Full Members. They are diabetic foot specialists from the various disciplines of diabetic foot management and care, from around the world. Full Members represent their respective country and vote at the General Assembly. To become a Full Member, individuals first apply to the Regional Council (see
our seven regions of national representatives) to become Provisional Member. The General Assembly admits Provisional Members as Full Members. In addition to Full and Provisional Members, D-Foot International has individual and institutional members: The Board admits individuals who make a financial contribution/ donation to the organisation as nonvoting Associate Members. The organisation also has non-voting Honorary Presidents and Honorary Members. The Board admits non-voting Institutional Members: associations to Association Members (e.g. regional study groups), and companies/ sponsors to Corporate Members. The Board creates standing committees: Audit and Risk Management Committee, Governance Committee, Ethics Committee, Advisory Committee.
The Board of D-Foot International is currently composed of 8 Directors: the President and 7 VicePresidents. A President-Elect will be chosen from among the members of the Board soon. A Vice-President Finance is being recruited. For the time being, and until the General Assembly in 2019, the Board exercises the powers of the General Assembly. The members of the Board are: President Kristien Van Acker Vice-Presidents Zulfiqarali G Abbas Neil Baker Nalini Campillo Shigeo Kono Stephan Morbach Mounia Sabasse Vilma UrbanÄ?iÄ? Rovan
D-Foot International promotes the global profile of diabetic foot prevention and management through awareness, guidance, education, research and professional development. Our aim is to improve diabetic foot care and the prevention/ reduction of unnecessary lower limb amputations from diabetes worldwide. With our global network of dedicated, specialised footcare representatives, we focus upon: • implementing the ’International Consensus on the Management and Prevention of the Diabetic Foot’ guidelines, • training healthcare professionals how identify, treat and manage diabetic foot problems effectively and to prevent unnecessary amputations, • giving healthcare professionals strategies to implement, develop and sustain foot services, • guiding healthcare professionals how to train and support their colleagues, • promoting the recognition of diabetic foot specialists. Our activities are arranged in 6 related and complementary Units: Awareness, Communication, Education, Implementation, Stakeholder Relations and Translation.
Hwang DJ, Lee KM, Park MS, Choi SH, Park JI, Cho JH, Park KH, Woo SJ. Association between diabetic foot ulcer and diabetic retinopathy. PLoS One. 2017 Apr 7; 12(4): e0175270. (PMID: 28388680) Two of the most common, and most commonly feared by patients, complications of the diabetes mellitus disease process are lower extremity pathology and retinopathy. This study found that 90% of patients suffering from a diabetic foot ulcer were also found to have some form of diabetic retinopathy. The authors appropriately conclude that patients suffering from foot pathology should be screened with a retinal examination (and vice versa), but more broadly this finding should impact the education all of us provide to our patients. Whether prescribing a local wound care protocol for an existing ulceration, or providing baseline education about daily foot checks during a scheduled lower extremity screening, a preponderance of the instruction we give patients with respect to their feet is reliant on their visual acuity. These results will certainly impact my patient education by including a general assessment of whether or not a patient has the actual physical capability of following these instructions.
Driver VR, Gould LJ, Dotson P, Gibbons GW, Li WW, Ennis WJ, Kirsner RS, Eaglstein WH, Bolton LL, Carter MJ. Identification and content validation of wound therapy clinical endpoints relevant to clinical practice and patient values for FDA approval. Part 1. Survey of the wound care community. (PMID: 28370922) This investigation presents results of a survey which sought to derive outcome measures with clinical significance utilized within the multidisciplinary wound community. Defining outcome measures is one of the most important aspects of any clinical investigation, and this can represent a challenge with respect to the diabetic foot. As the authors point out, complete wound healing as a primary outcome might not be realistic for all investigations and does not necessarily speak to overall patient care and function. Patient-reported outcomes and performance outcomes in the diabetic foot have not been as investigated with respect to validity and reliability. These results represent an important step forward both in terms translating the results of the medical literature into clinical practice and obtaining FDA approval of newly developed technologies.
Orneholm H, Apelqvist J, Larsson J, Eneroth M. Recurrent and other new foot ulcers after healed plantar forefoot diabetic ulcer. Wound Repair Regen. 2017 Apr 1 (PMID: 28370839) These investigators were able to prospectively follow a consecutive series of over 600 patients who had successfully healed a plantar forefoot ulceration for a two-year follow-up period. Of these, only 41% were confirmed to not develop a new ulceration over this period of time. This indicates that even in patients who undergo a successful course of intervention for a foot wound, a large majority will suffer from some form of subsequent adverse event. This data should help diabetic foot practitioners educate their patients both on their specific risk of ulceration recurrence and the importance of preventative measures.
Yapici O, Berk H, Oztoprak N, Seyman D, Tahmaz A, Merdin. Can ratio of neutrophil-to-lymphocyte coutn and erythrocyte sedimentation rate in diabetic foot infection predict osteomyelitis and/or amputation? Hematol Rep. 2017 Feb 23; 9(1): 6981. (PMID: 28286632) This brief case series of 75 patients provides evidence of another laboratory marker which might provide useful information with respect to the diagnosis of diabetic foot osteomyelitis. Most authoritative sources have now moved away from making this diagnosis based on a single “gold standard� or even the results of a single diagnostic test, and have instead emphasized relying on a combination of clinical, radiographic and laboratory findings. Specifically, these investigators simply performed calculation of the neutrophil-to-lymphocyte count ratio from a basic complete blood count, and found that elevated values were generally associated with worse clinical outcomes (need for debridement and need for amputation). This ratio compared well to other commonly utilized laboratory values such as the C-reactive protein and erythrocyte sedimentation rate, but did not require ordering an additional blood test. Values of this ratio greater than approximately 10 were associated with these worse clinical outcomes. This could represent a relatively simple measurement that provides just as much information as additional blood work.
Canales MB, Heurich ME, Mandela AM, Razzante MC. An approach to transmetatarsal amputation to encourage immediate weightbearing in diabetic patients. J Foot Ankle Surg. 2017 May-Jun; 56(3): 609-12. (PMID: 28258947). This is a brief technique report, but one which highlights the variable postoperative protocols present with respect to partial foot amputations and diabetic foot surgery. Specifically the authors describe suturing the plantar flap of a transmetatarsal amputation through drill holes in the remnant first, second and fourth metatarsals in order to facilitate early protected weightbearing on the first postoperative day. This early weightbearing has clear potential advantages in preventing the complications of immobilization and pressure wound development on both the index and contralateral extremity. More broadly, however, it points out how heavily surgeon preference plays into the post-operative protocols following diabetic foot surgery. I have found myself consistently surprised in how variable these can be among surgeons, even as it relates to commonly performed procedures such as the transmetatarsal amputation. As the sarcastic saying goes “nothing ruins good surgery like follow-up�, but the protocols and procedures of this follow-up might represent an interesting avenue for future investigations and educational events with respect to diabetic foot surgery.
Balderas-Pena LM, Sat-Munoz D, Ramirez-Conchas RE, Alvarado-Iniguez MR, Garcia-de-Alba-Carcia JE, CruzCorona E, Chavez-Hurtado JL, Chagollan-Ramierz JM. Descriptive, longitudinal study results applied to statistical models to assess the impact of early microbiology cultures on the economic burden of treatment for infected diabetic foot ulcers at a Mexican public health facility. Ostomy Wound Manage. 2016 Dec; 62(12): 14-28. (PMID: 28054923) This study applied data collected from a retrospective chart review to an economic predictive simulation, and observed that the use of early microbiology cultures in the treatment of infected diabetic foot ulcerations could reduce costs by approximately 30% within this urban cohort. They defined early collection as within 48 hours of admission. Most, but not all, of the cost differences were attributable to length of hospital stay. These findings demonstrate that although there might be some clinical discrepancy with respect to the appropriate way to collect culture data, and certainly some interesting new developments with respect to PCR culture analysis, early culture and antibiotic tailoring remains an important cornerstone in the treatment of diabetic foot infections.
Q ui z CLINICAL PICTURE “QUIZ” Welcome to this clinical picture quiz in your newsletter. Please have a good look at the x-ray. This is the left foot of a 37-year-old male with type 1 diabetes of 25 years’ duration. He has peripheral sensory and autonomic neuropathy with no clinical evidence of peripheral arterial disease. He presented with a warm swollen painless foot. Think about or write down what you can see and consider what action you might take and why. Here are a few questions below that you might guide you.
GUIDING QUESTIONS 1. What and where are any abnormalities you can see on this plain x-ray? 2. List each abnormality and determine which is the most likely presenting complaint. 3. For each abnormality try to think of any differential diagnosis . 4. Outline what your immediate, short and long-term interventions would be and their rationale.
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Key Observations 1. Generalised reduced bone density 2. Absent
nd 2 toe
+ head of met â&#x20AC;&#x201C; amputation
3. Callus formation around proximal shaft of
rd 3
metatarsal.
4. **Navicular fractured completely in two 2 5. Soft tissue swelling evident 6. Possible bipartite medial sesamoid
Clinical thoughts and management on observations 1. Generalised reduced bone density â&#x20AC;&#x201C; this appears to be a very common feature in people with diabetes and peripheral neuropathy. For many years it has been believed that peripheral neuropathy is in part responsible for poor bone density in the foot. However, interestingly evidence from a recent study in Australia (2016) does not support this and a systematic review also questions this theory concluding a nonsignificant association. Thus is this a clinically significant finding â&#x20AC;&#x201C; possibly? If so why and does it warrant any interventions? rd 3
2. The left toe and metatarsal head have been removed. The two most likely causes for this are either a traumatic incidence occurred warranting amputation or the toe was removed due to disease pathology. The latter is the most probable especially given the patients age. I would suggest that there was osteomyelitis or septic vasculitis in the digit which did not respond well to conservative management and may have involved the base of the proximal phalanx. If the head of the metatarsal had been involved I would have expected to see a more proximal resection of the metatarsal shaft. 3. Do there need to be any considerations for continuing care/interventions?
So now to the main presenting feature of this x-ray 1. The navicular has been fractured into 2 halves, probably due to trauma. It is an unusual place for a fracture and would require significant force and especially for one so pronounced. Fractures similar to this have been reported in professional athletes but the most reported are in armed service personnel. 2. The patient is neuropathic thus the most obvious consideration is: will he develop a Charcot neuroarthropathy? 3. Secondly, if he does not, will he be likely to develop a vascular necrosis of the navicular as the blood supply to this like the scaphoid in the wrist is poor? 4. There is a significant defect between the two parts of the navicular. Should this be pinned /repaired? 5. It would be sensible to immediately treat this as a potential Charcot and place in an off-loading cast. Interestingly one of the most common X-ray features associated with Charcot is absent here … medial wall arterial calcification. 6. Seeking an opinion from an orthopaedic surgeon would be useful if they are experienced and interested in diabetic foot pathology. 7. Long term management would clearly depend upon the clinical outcome, however this young man would require specialist footwear and foot orthoses as he will undoubtedly have a subsequent dysfunction mid-tarsal joint complex and altered gait. The role of this would be to facilitate the transition from midstance to forefoot loading and especially propulsion. 8. The soft tissue swelling/inflammation would reduce in a lower limb nonremovable cast but care/vigilance must be employed during the cast wearing process to ensure “cast induced” lesions do not occur. 9. The possible bipartite is a generally an anatomical variant and is not significant, purely an incidental finding. This is an unusual case but one that is interesting and useful to discuss with colleagues particularly concerning the concept and principles of short and long term management, including type and frequency of imaging, surgery or not, offloading, rehabilitation and follow-up pathways of care. We hope you found this interesting and we will present another clinical picture quiz in the next newsletter.
g n i ! m n o C oo s
D-Foot International