The implementation of a structured follow-up with the use of orthesis and shoes can reduce the incidence of DFU in diabetic patients who are at high ulcerative risk and its related costs.

OBJECTIVE—This study was designed to test the safety, effectiveness, and costs of off-loading with a novel, off-the-shelf irremovable device in the management of diabetic foot ulceration (DFU). RESEARCH DESIGN AND METHODS—We prospectively evaluated off-loading of neuropathic plantar ulcers in 40 diabetic outpatients attending our diabetic foot clinic and compared healing rates at the 12-week follow-up, number and severity of adverse events, healing time, costs and applicability of the device, and patients’ satisfaction between those randomly assigned to total contact casting (TCC; group A) or to the Optima Diab walker (group B). Deep or infected ulcers were excluded. RESULTS—No difference between groups A and B was observed in healing rates at 12 weeks (95 vs. 85%), healing time (6.5 ± 4.4 vs. 6.7 ± 3.4 weeks), and number of adverse events (six versus four). Treatment was significantly less expensive in group B, which showed a mean reduction of costs of 78% compared with group A (P < 0.001). Practicability was more favorable in group B, with a reduction of 77 and 58% of the time required for application and removal of the devices, respectively (P < 0.001). Patients’ satisfaction with the treatment was higher in group B (P < 0.01). CONCLUSIONS—The Optima Diab walker is as safe and effective as TCC in the management of DFU, but its lower costs and better applicability may be of help in spreading the practice of off-loading among the centers that manage the diabetic foot.

Contrast medium uptake rate obtained at D-MRI represents a reproducible parameter that is reliable for predicting and monitoring treatment outcome in acute Charcot foot.

OBJECTIVE -This study was designed to evaluate the histopathology of neuropathic ulcers and whether pressure relief could change such histological patterns. RESEARCH DESIGN AND METHODS-We compared neuropathic plantar ulcers tissue excised from 10 diabetic patients (group A) with those taken from 10 patients with comparable lesions and glycemic control after 20 days in a total contact cast (group B). Tissue specimens were blindly examined by two independent pathologists for hyperkeratosis, fibrosis, cutaneous annexes, capillaries, inflammation, cellular debris, and granulating tissue. For each parameter, quantification was obtained according to an arbitrary score: 0, absent; 1, present in Ͻ33%; 2, present in 34 -66%; and 3, present in Ͼ67% of the lesion.RESULTS -Patients in group B showed a marked reduction in ulcer size after 20 days of casting (P Ͻ 0.01). The histopathological features of the two groups markedly differed. Group A patients showed a predominance of inflammatory elements as well as matrix alterations, vessel disruptions, inflammation, and debris. Group B ulcers showed a shift toward a reparative pattern with prevalence of neoformed capillaries and fibroblasts. Semiquantitative analysis confirmed the prevalence of hyperkeratosis, fibrosis, inflammation, and cellular debris in group A patients (P Ͻ 0.05), whereas cutaneous annexes, capillaries, and granulating tissue were more prevalent in group B lesions (P Ͻ 0.01).CONCLUSIONS -These results indicate that pressure relief with a total contact cast is associated with changes in the histology of neuropathic foot ulcers, indicating reduction of inflammatory and reactive components and acceleration of reparative processes. Diabetes Care 26:3123-3128, 2003D iabetic neuropathic foot ulcers are a frequent late complication in diabetic patients and the most prevalent lesion of the diabetic foot. Neuropathy is the main determinant of plantar ulcers in diabetic patients (1), and the sequence of events leading to ulceration has been carefully described (2). A critical pathogenetic role is played by the loss of protective sensation due to sensitive neuropathy, which exposes the foot to abnormally high pressure. Concomitantly, modifications of the foot architecture due to motor neuropathy reduce the surfaces upon which increased forces persist. Hence, local hyperkeratosis develops that may be followed by an open lesion, the extension and depth of which are generally proportional to the postural stress (3,4).Much less is known on the histopathology of the open lesion. The few available studies have come to nonunivocal conclusions, although a common agreement exists supporting substantial histological modification associated with an interruption of tissue repair processes (5,6). The main drawbacks of these studies rely on the lack of uniformity of the methodology, the inclusion of ulcers with different etiology, and the lack of appropriate control lesions (7,8). Even more important, in all of these studies, biopsies of the lesions were obtained under noncontrolled...

Type II diabetic patients with microalbuminuria show an increased TERalb, i.e., a widespread microvascular damage that may be important in the pathogenesis of long-term complications. Our findings may contribute to the explanation of why albuminuria seems to be an independent cardiovascular risk factor in type II diabetes.