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Diabetic Foot
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Diabetic Foot

A special issue of Applied Sciences (ISSN 2076-3417). This special issue belongs to the section "Applied Biosciences and Bioengineering".

Deadline for manuscript submissions: closed (20 July 2022) | Viewed by 65730

Special Issue Editors

Dr. Zimi Sawacha

E-Mail Website
Guest Editor
Department of Information Engineering, University of Padova, 35131 Padova, Italy
Interests: gait and motion analysis in children and adults; musculoskeletal modeling and finite element modeling; foot and ankle biomechanics; plantar pressure sensors; electromyography; sport biomechanics and ACL injury prevention; data mining; Rehabilitation Engineering with special focus on diabetic foot; Parkinson’s disease and low back pain; markerless motion capture; multiple sensors integration
Special Issues, Collections and Topics in MDPI journals
Dr. Álvaro Astasio Picado

E-Mail Website
Guest Editor
Nursing and Physiotherapy Department, Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Talavera de la Reina, Toledo, Spain
Interests: diabetic foot; risk foot; medical thermography; infrared thermography; health sciences; surgery
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Chronic diabetes complications represent the most relevant problem in terms of clinical management, socio-economic impact, and healthcare system costs linked to diabetes. Ten years after disease onset, between 20 and 50% of patients develop diabetes neuropathy, which is a major risk factor for diabetic foot problems. This represents the most common cause of non-traumatic amputation. In the presence of neuropathy, elevated plantar pressure is an important risk factor for foot ulcer formation and maintenance. In recent years, there has been a large emphasis on the development of different approaches to diabetic foot prevention. The challenge for different healthcare professionals, such as clinicians and caregivers, bioengineers, computer engineers, and kinesiologists is to promote multidisciplinary approaches to diabetic foot prevention, which include physiological and functional monitoring technologies.

Recent developments in wearable sensing technologies, modeling, and biomechanics offer exciting opportunities for providing insights into novel and emerging biomarkers of diabetes and its complications with special reference to diabetic foot.

This Special Issue will present recent research findings on the development and application of sensor technologies in measurements and modeling of human biomechanical and physiological parameters associated with diabetic foot prevention. In particular, the Special Issue will report on various approaches including the application of biomechanical sensors (i.e., IMU, video analysis, plantar pressure, electromyography, force sensors) in the disease assessment, functional diagnosis, treatment, and rehabilitation; novel applications of continuous monitoring of both functional and physiological parameters in diabetic foot patients.

Dr. ZIMI SAWACHA
Prof. Dr. Álvaro Astasio Picado
Guest Editors

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Keywords

  • Diabetic foot biomechanics
  • plantar pressure
  • diabetic foot gait analysis
  • diabetic foot prevention
  • physiological modeling applied to diabetic foot
  • wearable sensors
  • diabetic foot biomarkers

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Published Papers (23 papers)

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19 pages, 7319 KiB  
Article
Efficient Computer-Based Method for Adjusting the Stiffness of Subject-Specific 3D-Printed Insoles during Walking
by Franziska Geiger, Maeruan Kebbach, Danny Vogel, Volker Weissmann and Rainer Bader
Appl. Sci. 2023, 13(6), 3854; https://doi.org/10.3390/app13063854 - 17 Mar 2023
Cited by 3 | Viewed by 2356
Abstract
Diabetes-adapted insoles are essential in prevention and rehabilitation of foot ulcers in diabetic foot syndrome. However, their manufacture is labour-intensive and costly. Therefore, the study aims to present an alternative method that allows the individual adjustment of the stiffness of the insoles using [...] Read more.
Diabetes-adapted insoles are essential in prevention and rehabilitation of foot ulcers in diabetic foot syndrome. However, their manufacture is labour-intensive and costly. Therefore, the study aims to present an alternative method that allows the individual adjustment of the stiffness of the insoles using the finite element (FE) method and subsequent 3D printing. In the study, 3D gait analysis followed by musculoskeletal modelling was used to determine the boundary conditions of a healthy subject for the FE model. While muscle forces are elaborately implemented in most studies, this FE model presented a more efficient way by using ankle moments and joint reaction forces. The deviation between the simulated plantar peak pressure and the experimentally determined using the Pedar system amounted to 234 kPa in the heel area and 30 kPa in the toe area. The stiffness of the individual insole was adjusted by applying soft insole plugs in areas where high plantar pressures occurred during walking. Three different Young’s moduli were analysed in these areas (0.5 MPa, 1.0 MPa, 1.5 MPa). The computer-based approach to adjust the stiffness of an individual insole revealed a plantar peak pressure reduction by 37% in the heel area and by 119% in the toe area with a Young’s modulus of 0.5 MPa. The presented method could be a valuable tool in the cost-efficient development and engineering of subject-specific 3D-printed insoles for patients with diabetic foot syndrome. Full article
(This article belongs to the Special Issue Diabetic Foot)
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11 pages, 2933 KiB  
Article
Preservation Surgery of Septic Osteoarthritis and Osteomyelitis in the Diabetic Foot Using S53P4 Bioactive Glass—A Case Series
by Iza Korpar and Igor Frangež
Appl. Sci. 2023, 13(5), 3310; https://doi.org/10.3390/app13053310 - 05 Mar 2023
Viewed by 1328
Abstract
(1) Background: Preservation surgery of the diabetic foot aims at tissue sparing to avoid further pathological changes from developing, while ultimately preserving the limb. For this purpose, osteoregenerative, antimicrobial, and osteostimulative materials are now available. The aim of this case series is to [...] Read more.
(1) Background: Preservation surgery of the diabetic foot aims at tissue sparing to avoid further pathological changes from developing, while ultimately preserving the limb. For this purpose, osteoregenerative, antimicrobial, and osteostimulative materials are now available. The aim of this case series is to demonstrate several clinical situations in which the use of bioactive glass, a third-generation biomaterial, can potentially be of benefit. (2) Methods: In this retrospective case series, we present patients with a diabetic foot complication with septic osteoarthritis, treated at the University Medical Centre Ljubljana, in the years 2020–2022. Patients received surgical care with resection of the affected joint and bone and placement of bioactive glass material. We observed patient characteristics, recurrence of septic osteoarthritis or osteomyelitis, and the need for amputation in the follow-up period. (3) Results: Of the 16 included patients, 8 received treatment of the metatarsophalangeal joints, 4 of the midfoot joints, and 4 of the ankle joints. Ten suffered from Charcot neuroarthropathy. None required readmission within 30 days or suffered early complications. One complication with recidivant septic osteoarthritis and osteomyelitis was observed. (4) Conclusions: Our case series presents possible applications for treatment with bioactive glass in various joints and bones affected by septic osteoarthritis of the diabetic foot. Full article
(This article belongs to the Special Issue Diabetic Foot)
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10 pages, 1186 KiB  
Article
Analysis of Factors Associated with Charcot Neuroarthropathy following Pancreatic Transplantation
by Naohiro Aida, Taihei Ito, Kei Kurihara, Izumi Hiratsuka, Megumi Shibata, Atsushi Suzuki and Takashi Kenmochi
Appl. Sci. 2023, 13(4), 2670; https://doi.org/10.3390/app13042670 - 19 Feb 2023
Viewed by 917
Abstract
Charcot neuroarthropathy (CN) is a progressive neuropathic complication of diabetes mellitus. Patients undergoing pancreatic transplantation are at risk of developing CN, and CN is known to be a poor prognostic factor for graft loss and patient death. This study aimed to investigate the [...] Read more.
Charcot neuroarthropathy (CN) is a progressive neuropathic complication of diabetes mellitus. Patients undergoing pancreatic transplantation are at risk of developing CN, and CN is known to be a poor prognostic factor for graft loss and patient death. This study aimed to investigate the factors associated with CN in patients who had undergone pancreatic transplantation. We analyzed the data of 61 patients who underwent pancreatic transplantations to investigate the relationship between patient background, nerve conduction velocity tests prior to transplantation, and CN onset. Of these patients, six developed CN. The cumulative incidence rates at 1, 3, and 5 years after transplantation were 3.3, 6.9, and 9.0%, respectively. Sensory neuropathy was severe in six patients with CN, with no sural nerve waveform detected. CN development was not observed when the sural nerve waveforms were visualized. However, when no sural nerve waveforms were observed, the incidence of CN significantly increased due to high-dose corticosteroid administration (p = 0.036). High-dose corticosteroids are associated with the development of CN in the presence of severe neuropathy. Corticosteroid administration is associated with bone metabolism; therefore, appropriate therapeutic intervention is required. Full article
(This article belongs to the Special Issue Diabetic Foot)
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12 pages, 6213 KiB  
Article
The Effect of Custom Insoles on Muscle Activity in Diabetic Individuals with Neuropathy
by Fabiola Spolaor, Annamaria Guiotto, Alfredo Ciniglio and Zimi Sawacha
Appl. Sci. 2023, 13(4), 2326; https://doi.org/10.3390/app13042326 - 11 Feb 2023
Viewed by 1697
Abstract
Foot ulcers are amongst the most serious complications of diabetes. Guidelines recommend that people with diabetes wear appropriate footwear or insoles to reduce repetitive stresses. Excessive plantar pressure has been recognized as the major risk factor for plantar ulcers in diabetic individuals; custom [...] Read more.
Foot ulcers are amongst the most serious complications of diabetes. Guidelines recommend that people with diabetes wear appropriate footwear or insoles to reduce repetitive stresses. Excessive plantar pressure has been recognized as the major risk factor for plantar ulcers in diabetic individuals; custom insoles are indicated as the gold standard treatment to unload the foot structure. The aim of this study was to investigate the effect of custom insoles on biomechanical and neuromuscular functions in diabetic neuropathic individuals. Ten diabetic subjects walked with and without custom insoles at their preferred speed; ten controls were assessed for comparison. Data were captured through seven video cameras, plantar pressure insoles, and surface electromyography. The electrical activity of Rectus Femoris, Tibialis Anterior, Medius Gluteus and Gastrocnemius Lateralis were acquired bilaterally. The plantar pressure and surface electromyographic variables were determined, while videos were used to detect the gait cycle. The following comparisons were made across the variables through the non-parametric SPM1D test (p < 0.05): condition with vs. without insoles vs. controls. Custom insoles provided a reduction in plantar pressure through contact surface redistribution in association with a reduced electromyographic activity. Our results suggest optimizing the prevention approach by including personalized foot and ankle exercises. Full article
(This article belongs to the Special Issue Diabetic Foot)
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16 pages, 4540 KiB  
Article
Proposal of a Non-Invasive Measurement of Physical Properties of Tissues in Patients with Diabetic Foot: Measurement Experiences in Diagnosed Patients
by Ilse Anahi Torres, Lorenzo Leija, Arturo Vera, Daniela Ávila, Héctor Maldonado, Josefina Gutiérrez, Marisela Carrillo, Mario Ibrahín Gutiérrez and Antonio Ramos
Appl. Sci. 2023, 13(4), 2026; https://doi.org/10.3390/app13042026 - 04 Feb 2023
Cited by 1 | Viewed by 1474
Abstract
Diabetic foot is one of the most serious complications in patients with diabetes mellitus. It is distinguished by the development of ulcerations on the sole of the foot. Before the appearance of these, patients with diabetes suffer changes in the tissues of the [...] Read more.
Diabetic foot is one of the most serious complications in patients with diabetes mellitus. It is distinguished by the development of ulcerations on the sole of the foot. Before the appearance of these, patients with diabetes suffer changes in the tissues of the foot and nearby tissues. This work proposes systems that measure and identify the changes in the physical characteristics of the foot tissues in two study groups, diabetic patients and healthy subjects, with the purpose of proposing tools to physicians to follow up each patient and identify with certainty the evolution in symptoms. The results of the temperature systems show that there is an average temperature difference of ~2 °C between diabetic patients and healthy subjects. Using an electrical impedance system, a frequency window was found between 5 kHz and 22 kHz, where the impedance is significantly different (p > 0.001) between diabetic and healthy patients. The system oriented to macules on the skin is able to identify the type of macules developed by the diabetic patient. In temperature measurement with images from a smartphone, plantar temperature monitoring was achieved in at-risk areas in uncontrolled environments. The results presented in this work were obtained in a time period from 2014 to 2022. Considering the standardization of this equipment when making a diagnosis regarding the study of tissues in the diabetic foot, it will be possible to detect it early. Through differences between the measurements, we have an indicator of the patient’s evolution, and we must highlight that these systems are easy to install, easy to interpret and low cost. Currently, there are no systems with these characteristics, which is why the early detection of diabetic foot is being widely studied. Full article
(This article belongs to the Special Issue Diabetic Foot)
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15 pages, 1133 KiB  
Article
Effects of a Home-Based Foot–Ankle Exercise Program with Educational Booklet for Foot Dysfunctions in People with Diabetic Neuropathy: Results of the FOCA-II Randomized Controlled Clinical Trial
by Érica Q. Silva, Jady L. Veríssimo, Jane S. S. P. Ferreira, Ronaldo H. Cruvinel-Júnior, Renan L. Monteiro, Eneida Y. Suda and Isabel C. N. Sacco
Appl. Sci. 2023, 13(3), 1423; https://doi.org/10.3390/app13031423 - 20 Jan 2023
Cited by 1 | Viewed by 1971
Abstract
Exercise rehabilitation and education are important strategies for preventing the progression of diabetic neuropathy-related musculoskeletal deficits. The purpose of this randomized controlled trial was to investigate the effect of an 8-week home-based foot–ankle exercise program using an educational booklet on clinical outcomes (foot [...] Read more.
Exercise rehabilitation and education are important strategies for preventing the progression of diabetic neuropathy-related musculoskeletal deficits. The purpose of this randomized controlled trial was to investigate the effect of an 8-week home-based foot–ankle exercise program using an educational booklet on clinical outcomes (foot muscle strength and functionality; functional balance; diabetic neuropathy symptoms and severity; tactile and vibratory sensitivities; plantar pressure distribution; and foot–ankle, knee, and hip biomechanics during gait). Fifty participants with neuropathy were randomly allocated into an intervention group (59.1 ± 6.4 years, 23.5 ± 4.8 kg/m2, males = 6, females = 19) that performed the exercises for 8 weeks and a control group (56.5 ± 9.4 years, 22.9 ± 3.6 kg/m2, males = 5, females = 20) that received usual care recommendations. Generalized estimating equation method and intention-to-treat approaches were adopted. No significant differences were found for any clinical outcome after 8 weeks. Heel contact area increased in the intervention group compared to controls (p = 0.043, mean difference = 2.7 cm) and heel peak pressure was increased in controls compared to intervention (group effect p = 0.020, mean difference = -64.16 kPa) at 8 weeks. Controls showed increased joint moments for the hip at heel strike (p = 0.007) and for the knee and hip at push off over 8 and 16 weeks (p < 0.001 and p = 0.009, respectively). Although the intervention is easy to perform and showed a good adherence (72%), home-based foot–ankle exercise programs are unlikely to sufficiently modify the main risk factors related to foot ulcers and to change foot–ankle kinematics and kinetics. Full article
(This article belongs to the Special Issue Diabetic Foot)
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13 pages, 3482 KiB  
Article
First Report on the Phenotypic and Genotypic Susceptibility Profiles to Silver Nitrate in Bacterial Strains Isolated from Infected Leg Ulcers in Romanian Patients
by Mihaela Georgescu, Corneliu Ovidiu Vrancianu, Marcela Popa, Irina Gheorghe and Mariana Carmen Chifiriuc
Appl. Sci. 2022, 12(10), 4801; https://doi.org/10.3390/app12104801 - 10 May 2022
Viewed by 1669
Abstract
Silver-ion-based antiseptics are widely used in treating chronic leg ulcers and, given the emergence of resistance to such compounds, the investigation of silver susceptibility and resistance profiles of pathogenic strains isolated from this type of wound is a topic of great interest. Therefore, [...] Read more.
Silver-ion-based antiseptics are widely used in treating chronic leg ulcers and, given the emergence of resistance to such compounds, the investigation of silver susceptibility and resistance profiles of pathogenic strains isolated from this type of wound is a topic of great interest. Therefore, in this study, 125 bacterial strains isolated from 103 patients with venous ulcers were investigated to elucidate their susceptibility to silver-nitrate solutions in planktonic and biofilm growth states, and the associated genetic determinants. The isolated strains, both in the planktonic and biofilm growth phases, showed high sensitivity to the standard concentration of 1/6000 silver-nitrate solution. It was noticed that even at concentrations lower than the clinical one (the first 2–3 binary dilutions in the case of planktonic cultures and the first 6–7 binary dilutions in the case of biofilms), the antiseptic solution proved to maintain its antibacterial activity. The phenotypic results were correlated with the genetic analysis, highlighting the presence of silver-resistance genes (sil operon) in only a few of the tested Staphylococcus sp. (especially in S. aureus) strains, Escherichia coli and Pseudomonas aeruginosa strains. These results demonstrate that despite its large use, this antiseptic remains a viable treatment alternative for the management of chronic leg wounds. Full article
(This article belongs to the Special Issue Diabetic Foot)
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8 pages, 864 KiB  
Article
Does Amputation Negatively Influence the Incidence of Depression in Diabetic Foot Patients? A Population-Based Nationwide Study
by Dong-Il Chun, Jahyung Kim, Eun Myeong Kang, Chi Young An, Tae-Hong Min, Sangyoung Kim, Jaeho Cho, Young Yi and Sung Hun Won
Appl. Sci. 2022, 12(3), 1653; https://doi.org/10.3390/app12031653 - 04 Feb 2022
Cited by 1 | Viewed by 2451
Abstract
This study aimed to investigate the relationship between diabetic foot ulcer and depression based on treatment methods employed, as evaluated according to Medicare claims data provided by the Health Insurance Review and Assessment Service (HIRA). Data on diabetic foot patients from January 2011 [...] Read more.
This study aimed to investigate the relationship between diabetic foot ulcer and depression based on treatment methods employed, as evaluated according to Medicare claims data provided by the Health Insurance Review and Assessment Service (HIRA). Data on diabetic foot patients from January 2011 to December 2016 were collected from the HIRA using codes for diabetic foot and depression disorder. The incidence of depression was analyzed based on patients’ demographic variables, and comorbidities were assessed using the Charlson comorbidity index (CCI). The participants were divided into two groups based on the treatment method used: a limb-saving group and an amputation group. The 1-, 3-, and 5-year incidence rates of depression were 10.1%, 20.4%, and 29.5%, respectively, in the limb-saving group and 4.5%, 8.2%, and 11.5%, respectively, in the amputation group. Female sex, the CCI, and the use of limb-saving treatment methods were significant risk factors. It is plausible that depression in diabetic foot patients may be associated with frequent recurrence and chronicity rather than a single intense event. Our findings highlight the need for clinicians to consider the treatment period as a contributor to patient mood disorders when selecting the appropriate course of action in patients. Full article
(This article belongs to the Special Issue Diabetic Foot)
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16 pages, 8707 KiB  
Article
Analysis of Clinical Profiles, Deformities, and Plantar Pressure Patterns in Diabetic Foot Syndrome
by Claudia Giacomozzi, Giada Lullini, Alberto Leardini, Paolo Caravaggi, Maurizio Ortolani, Giulio Marchesini, Luca Baccolini and Lisa Berti
Appl. Sci. 2021, 11(23), 11464; https://doi.org/10.3390/app112311464 - 03 Dec 2021
Cited by 2 | Viewed by 1676
Abstract
Diabetic foot syndrome refers to heterogeneous clinical and biomechanical profiles, which render predictive models unsatisfactory. A valuable contribution may derive from identification and descriptive analysis of well-defined subgroups of patients. Clinics, biology, function, gait analysis, and plantar pressure variables were assessed in 78 [...] Read more.
Diabetic foot syndrome refers to heterogeneous clinical and biomechanical profiles, which render predictive models unsatisfactory. A valuable contribution may derive from identification and descriptive analysis of well-defined subgroups of patients. Clinics, biology, function, gait analysis, and plantar pressure variables were assessed in 78 patients with diabetes. In 15 of them, the 3D architecture of the foot bones was characterized by using weight-bearing CT. Patients were grouped by diabetes type (T1, T2), presence (DN) or absence (DNN) of neuropathy, and obesity. Glycated hemoglobin (HbA1c) and plantar lesions were monitored during a 48-month follow-up. Statistical analysis showed significant differences between the groups for at least one clinical (combined neuropathy score, disease duration, HbA1c), biological (age, BMI), functional (joint mobility, foot alignment), or biomechanical (regional peak pressure, pressure-time integral, cadence, velocity) variable. Twelve patients ulcerated during follow-up (22 lesions in total), distributed in all groups but not in the DNN T2 non-obese group. These showed biomechanical alterations, not always occurring at the site of lesion, and HbA1c and neuropathy scores higher than the expected range. Three of them, who also had weight-bearing CT analysis, showed >40% of architecture parameters outside the 95%CI. Appropriate grouping and profiling of patients based on multi-instrumental clinical and biomechanical analysis may help improve prediction modelling and management of diabetic foot syndrome. Full article
(This article belongs to the Special Issue Diabetic Foot)
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15 pages, 3343 KiB  
Article
The Effect of Neuropathy and Diabetes Type on Multisegment Foot Kinematics: A Cohort Study on 70 Participants with Diabetes
by Paolo Caravaggi, Claudia Giacomozzi, Giada Lullini, Giulio Marchesini, Luca Baccolini, Maurizio Ortolani, Isabel C. N. Sacco, Lisa Berti and Alberto Leardini
Appl. Sci. 2021, 11(19), 8848; https://doi.org/10.3390/app11198848 - 23 Sep 2021
Cited by 3 | Viewed by 1656
Abstract
While lower limb biomechanics of people with diabetes are well described, the effects of diabetes type and of peripheral neuropathy on foot joint kinematics have not been addressed in depth. A total of 70 patients with type 1 (n = 25) and type [...] Read more.
While lower limb biomechanics of people with diabetes are well described, the effects of diabetes type and of peripheral neuropathy on foot joint kinematics have not been addressed in depth. A total of 70 patients with type 1 (n = 25) and type 2 (n = 45) diabetes mellitus, with and without peripheral neuropathy, underwent functional evaluation via gait analysis using an established multisegment foot kinematic model. ANCOVA was performed to assess differences in foot joints’ range of motion (ROM) between groups with diabetes and a control group by accounting for the effects of age, body mass index (BMI) and normalized walking speed. Statistical parametric mapping was used to assess differences in temporal patterns of foot joint motion across normalized gait cycle. Small but significant correlations were found between age, BMI, speed and foot joints’ ROM. Regardless of diabetes type and presence of neuropathy, all subgroups with diabetes showed limited ROM at the midtarsal and tarsometatarsal joints. Increased midtarsal joint dorsiflexion and adduction was associated with increased tarsometatarsal joint plantarflexion. After accounting for the effect of covariates, diabetes is associated with reduced ROM and to alterations of the kinematic patterns, especially at the midtarsal and tarsometatarsal joints, irrespective of type and neuropathy. Full article
(This article belongs to the Special Issue Diabetic Foot)
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14 pages, 1720 KiB  
Article
A Novel Bathing Therapeutic Approach for Diabetic Foot Ulcers
by Paramjit S. Tappia, Brett Hiebert, Rohan Sanjanwala, Paul Komenda, Chris Sathianathan, Amarjit S. Arneja and Bram Ramjiawan
Appl. Sci. 2021, 11(18), 8402; https://doi.org/10.3390/app11188402 - 10 Sep 2021
Cited by 2 | Viewed by 2219
Abstract
Ineffective healing and treatment of foot ulcers can lead to an infection and gangrene of the wound area that ultimately results in the loss of the limb. The incidence of foot ulcers is higher in patients with diabetes, peripheral vascular disease and kidney [...] Read more.
Ineffective healing and treatment of foot ulcers can lead to an infection and gangrene of the wound area that ultimately results in the loss of the limb. The incidence of foot ulcers is higher in patients with diabetes, peripheral vascular disease and kidney disease. Accordingly, this study was undertaken to assess the ability of foot bathing in CO2-enriched water to heal foot ulcers. The design was a double-blinded, randomized, placebo-controlled study. Patients with at least one foot ulcer were randomized to receive either a treatment with bath therapy at 37 ± 0.5 °C containing either 1000–1200 ppm CO2-enriched tap water (the intervention) or non-carbonated tap water at 37 ± 0.5 °C (the control group). Treatment was conducted three times/week for 15 min per session for up to 16 weeks for a total of 48 treatment sessions. Before and at the end of every treatment month, wound size, wound area oxygenation and the ankle brachial index were measured. In addition, the McGill pain questionnaire was conducted. Blood was also collected at these time points (for a total of five collections) for the measurement of different biomarkers. While no significant differences (p < 0.05) in the group/time interaction effect were observed, a clear separation within the wound area reduction/wound area/oxygenated Hb outcomes was seen between placebo (control) and treatment (CO2) group. This pilot study is suggestive that bathing in CO2-enriched water may accelerate the healing of foot ulcers. Full article
(This article belongs to the Special Issue Diabetic Foot)
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12 pages, 2441 KiB  
Article
The Thermo-Pressure Concept: A New Model in Diabetic Foot Risk Stratification
by Sarah Perren, Cynthia Formosa, Liberato Camilleri, Nachiappan Chockalingam and Alfred Gatt
Appl. Sci. 2021, 11(16), 7473; https://doi.org/10.3390/app11167473 - 14 Aug 2021
Cited by 3 | Viewed by 2941
Abstract
Elevated foot pressure and high temperatures have been proposed as predictive factors for diabetic foot ulceration; however, on their own, their predictive value is still questionable. This pilot study hypothesized that combining these two measurements in a thermo-pressure model could result in a [...] Read more.
Elevated foot pressure and high temperatures have been proposed as predictive factors for diabetic foot ulceration; however, on their own, their predictive value is still questionable. This pilot study hypothesized that combining these two measurements in a thermo-pressure model could result in a more reliable risk assessment tool for providing risk categorization aimed to determine whether there is a correlation between foot plantar pressure and temperature in patients living with diabetes mellitus (DM) when compared with healthy individuals following a 15 min walk. Foot pressure and thermographic images were taken from 48 participants who were categorised into four groups following clinical evaluation into healthy individuals (Group A), living with DM with no complications (Group B), DM with peripheral arterial disease (Group C) and DM patients with neuropathy (Group D). This study demonstrated a positive correlation between pressure and temperature; as pressure increases, so does temperature. This was more pronounced in the groups with DM when compared to the healthy group. More research is warranted to further develop this innovative thermo-pressure model, which could hopefully be more sensitive in categorizing and identifying patients living with DM who are at risk of developing foot ulceration to initiate prompt care. Full article
(This article belongs to the Special Issue Diabetic Foot)
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17 pages, 13960 KiB  
Article
Morphological Foot Model for Temperature Pattern Analysis Proposed for Diabetic Foot Disorders
by Natalia Arteaga-Marrero, Lucas Christian Bodson, Abián Hernández, Enrique Villa and Juan Ruiz-Alzola
Appl. Sci. 2021, 11(16), 7396; https://doi.org/10.3390/app11167396 - 11 Aug 2021
Cited by 3 | Viewed by 2235
Abstract
Infrared thermography is a non-invasive and accessible tool that maps the surface temperature of a body. This technology is particularly useful for diabetic foot disorders, since it facilitates the identification of higher risk patients by frequent monitoring and therefore limits the incidence of [...] Read more.
Infrared thermography is a non-invasive and accessible tool that maps the surface temperature of a body. This technology is particularly useful for diabetic foot disorders, since it facilitates the identification of higher risk patients by frequent monitoring and therefore limits the incidence of disabling conditions. The aim of this work is to provide a methodology to explore the entire plantar aspects of both feet, based on infrared thermography, for the assessment of diabetic foot anomalies. A non-invasive methodology was established to identify areas of higher risk and track their progress via longitudinal monitoring. A standard morphological model was extracted from a group of healthy subjects, nine females and 13 males, by spatial image registration. This healthy foot model can be taken as a template for the assessment of temperature asymmetry, even in cases in which partial amputations or deformations are present. A pixel-wise comparison of the temperature patterns was carried out by Wilcoxon´s matched-pairs test using the corresponding template. For all the subjects, the left foot was compared to the contralateral foot, the right one, providing a map of statistically significant areas of variation, within the template, among the healthy subjects at different time points. In the female case, the main areas of variability were the boundaries of the feet, whereas for the male, in addition to this, substantial changes that exhibited a clear pattern were observed. A fast and simple monitoring tool is provided to be used for personalized medical diagnosis in patients affected by diabetic foot disorders. Full article
(This article belongs to the Special Issue Diabetic Foot)
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16 pages, 2628 KiB  
Article
Not Only Antimicrobial: Metronidazole Mitigates the Virulence of Proteus mirabilis Isolated from Macerated Diabetic Foot Ulcer
by Ahdab N. Khayyat, Hisham A. Abbas, Mamdouh F. A. Mohamed, Hani Z. Asfour, Maan T. Khayat, Tarek S. Ibrahim, Mahmoud Youns, El-Sayed Khafagy, Amr S. Abu Lila, Martin K. Safo and Wael A. H. Hegazy
Appl. Sci. 2021, 11(15), 6847; https://doi.org/10.3390/app11156847 - 26 Jul 2021
Cited by 32 | Viewed by 4968
Abstract
Diabetic foot ulcers are recognized to be a severe complication of diabetes, increasing the risk of amputation and death. The bacterial infection of Diabetic foot ulcers with virulent and resistant bacteria as Proteus mirabilis greatly worsens the wound and may not be treated [...] Read more.
Diabetic foot ulcers are recognized to be a severe complication of diabetes, increasing the risk of amputation and death. The bacterial infection of Diabetic foot ulcers with virulent and resistant bacteria as Proteus mirabilis greatly worsens the wound and may not be treated with conventional therapeutics. Developing new approaches to target bacterial virulence can be helpful to conquer such infections. In the current work, we evaluated the anti-virulence activities of the widely used antibacterial metronidazole. The minimum inhibitory concentrations (MIC) and minimum biofilm eradication concentrations (MEBC) were determined for selected antibiotics which P. mirabilis was resistant to them in the presence and absence of metronidazole in sub-MIC. The effect of metronidazole in sub-MIC on P. mirabilis virulence factors as production of exoenzymes, motilities, adhesion and biofilm formation, were evaluated. Furthermore, molecular docking of metronidazole into P. mirabilis adhesion and essential quorum sensing (QS) proteins, was performed. The results revealed a significant ability of metronidazole to in-vitro inhibit P. mirabilis virulence factors and antagonize its essential proteins. Moreover, metronidazole markedly decreased the MICs and MBECs of tested antibiotics. Conclusively, metronidazole in sub-MIC is a plausible anti-virulence and anti-QS agent that can be combined to other antibiotics as anti-virulence adjuvant to defeat aggressive infections. Full article
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11 pages, 296 KiB  
Article
Impact on the Quality of Life and Physiological Parameters in Patients with Diabetes Mellitus
by María Reina-Bueno, Inmaculada C. Palomo-Toucedo, Manuel Ángel Medina-Núñez, Pedro V. Munuera-Martínez, Aurora Castro-Méndez and María del Carmen Vázquez-Bautista
Appl. Sci. 2021, 11(15), 6829; https://doi.org/10.3390/app11156829 - 25 Jul 2021
Viewed by 2202
Abstract
The co-existence of complications and diabetes mellitus is related to a worsening in quality of life compared to not presenting comorbidities. This study aimed to investigate whether there is a different impact on quality of life according to gender and to establish the [...] Read more.
The co-existence of complications and diabetes mellitus is related to a worsening in quality of life compared to not presenting comorbidities. This study aimed to investigate whether there is a different impact on quality of life according to gender and to establish the physiological parameters that these patients have in relation to diabetes-related complications. The sampling was continuous non-probabilistic, involving legal age patients with diabetes mellitus. All of the participants were administered the generic SF-36 quality of life questionnaire. The presence of peripheral artery disease was considered from an ankle brachial index <0.9 and grade II to grade IV of the Leriche–Fontaine classification. Nerve dysfunction was detected from a neurotensiometer test, and the presence of diabetic foot was detected from a dermal examination and co-existence with arteriopathy and/or neuropathy. Men presented significantly better quality of life values on the mental health, emotional role and health transition scales. Despite this, in the presence of complications such as vasculopathy, neuropathy or diabetic foot, the perception of well-being changes, showing that men and women face the disease in different ways. Despite the fact that the physical parameters of diabetic patients are similar according to the complications that they present, the adult women in our environment have lower levels of quality of life than men in most cases. This may be related not only to pathophysiological differences but also to sociocultural factors. Full article
(This article belongs to the Special Issue Diabetic Foot)
8 pages, 822 KiB  
Article
The Effect of Transcutaneous Application of Gaseous CO2 on Diabetic Symmetrical Peripheral Neuropathy—A Double-Blind Randomized Clinical Trial
by Helena Ban Frangež, Zoran Rodi, Jana Miklavčič and Igor Frangež
Appl. Sci. 2021, 11(11), 4911; https://doi.org/10.3390/app11114911 - 27 May 2021
Cited by 4 | Viewed by 2286
Abstract
Aim: Diabetic symmetrical peripheral neuropathy is a common complication of diabetes mellitus. Patients treated with transcutaneous CO2 application for chronic wounds reported an improvement in peripheral sensations. This study aimed to evaluate the effect of transcutaneous application of gaseous CO2 on [...] Read more.
Aim: Diabetic symmetrical peripheral neuropathy is a common complication of diabetes mellitus. Patients treated with transcutaneous CO2 application for chronic wounds reported an improvement in peripheral sensations. This study aimed to evaluate the effect of transcutaneous application of gaseous CO2 on diabetic symmetrical peripheral neuropathy. Methods: A prospective randomized, double-blind study was performed at the University Medical Center Ljubljana between September 2019 and September 2020. Sixty consecutive patients with diabetes with a unilateral chronic wound were randomized into either a study group that received transcutaneous CO2 therapy or a control group that received placebo treatment with air. Results: Vibration, monofilament sensation, and temperature of the big toe improved significantly in the study group (p < 0.001, for vibration sensation, monofilament test and temperature of the big toe), but not in the control group (p = ns for all evaluated outcomes). Conclusion: According to our results, a transcutaneous application of gaseous CO2 shows promising results in treating diabetic symmetrical peripheral neuropathy. Considering the major consequences of sensory loss leading to foot ulceration and possibly amputation, we believe this treatment approach deserves future attention and investigation as a treatment modality of diabetic symmetrical peripheral neuropathy. Full article
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Review

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23 pages, 1358 KiB  
Review
Old and Novel Predictors for Cardiovascular Risk in Diabetic Foot Syndrome—A Narrative Review
by Cristina Andreea Adam, Dragos Traian Marius Marcu, Ovidiu Mitu, Mihai Roca, Viviana Aursulesei Onofrei, Mihai Lucian Zabara, Laura Carina Tribuș, Carmen Cumpăt, Radu Crișan Dabija and Florin Mitu
Appl. Sci. 2023, 13(10), 5990; https://doi.org/10.3390/app13105990 - 12 May 2023
Cited by 1 | Viewed by 1762
Abstract
Diabetic foot syndrome (DFS) is a complication associated with diabetes that has a strong negative impact, both medically and socio-economically. Recent epidemiological data show that one in six patients with diabetes will develop an ulcer in their lifetime. Vascular complications associated with diabetic [...] Read more.
Diabetic foot syndrome (DFS) is a complication associated with diabetes that has a strong negative impact, both medically and socio-economically. Recent epidemiological data show that one in six patients with diabetes will develop an ulcer in their lifetime. Vascular complications associated with diabetic foot have multiple prognostic implications in addition to limiting functional status and leading to decreased quality of life for these patients. We searched the electronic databases of PubMed, MEDLINE and EMBASE for studies that evaluated the role of DFS as a cardiovascular risk factor through the pathophysiological mechanisms involved, in particular the inflammatory ones and the associated metabolic changes. In the era of evidence-based medicine, the management of these cases in multidisciplinary teams of “cardio-diabetologists” prevents the occurrence of long-term disabling complications and has prognostic value for cardiovascular morbidity and mortality among diabetic patients. Identifying artificial-intelligence-based cardiovascular risk prediction models or conducting extensive clinical trials on gene therapy or potential therapeutic targets promoted by in vitro studies represent future research directions with a modulating role on the risk of morbidity and mortality in patients with DFS. Full article
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13 pages, 650 KiB  
Review
Artificial Intelligence Based Prediction of Diabetic Foot Risk in Patients with Diabetes: A Literature Review
by Lucija Gosak, Adrijana Svensek, Mateja Lorber and Gregor Stiglic
Appl. Sci. 2023, 13(5), 2823; https://doi.org/10.3390/app13052823 - 22 Feb 2023
Cited by 3 | Viewed by 2544
Abstract
Diabetic foot is a prevalent chronic complication of diabetes and increases the risk of lower limb amputation, leading to both an economic and a major societal problem. By detecting the risk of developing diabetic foot sufficiently early, it can be prevented or at [...] Read more.
Diabetic foot is a prevalent chronic complication of diabetes and increases the risk of lower limb amputation, leading to both an economic and a major societal problem. By detecting the risk of developing diabetic foot sufficiently early, it can be prevented or at least postponed. Using artificial intelligence, delayed diagnosis can be prevented, leading to more intensive preventive treatment of patients. Based on a systematic literature review, we analyzed 14 articles that included the use of artificial intelligence to predict the risk of developing diabetic foot. The articles were highly heterogeneous in terms of data use and showed varying degrees of sensitivity, specificity, and accuracy. The most used machine learning techniques were support vector machine (SVM) (n = 6) and K-Nearest Neighbor (KNN) (n = 5). Future research is recommended on larger samples of participants using different techniques to determine the most effective one. Full article
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31 pages, 2386 KiB  
Review
Hyperglycaemia-Linked Diabetic Foot Complications and Their Management Using Conventional and Alternative Therapies
by Prawej Ansari, Samia Akther, Joyeeta T. Khan, Sara S. Islam, Md. Samim R. Masud, Anisur Rahman, Veronique Seidel and Yasser H. A. Abdel-Wahab
Appl. Sci. 2022, 12(22), 11777; https://doi.org/10.3390/app122211777 - 19 Nov 2022
Cited by 8 | Viewed by 7471
Abstract
Diabetes mellitus, a major cause of mortality around the globe, can result in several secondary complications, including diabetic foot syndrome, which is brought on by diabetic neuropathy and ischemia. Approximately 15% of diabetic patients suffer from diabetic foot complications, and among them 25% [...] Read more.
Diabetes mellitus, a major cause of mortality around the globe, can result in several secondary complications, including diabetic foot syndrome, which is brought on by diabetic neuropathy and ischemia. Approximately 15% of diabetic patients suffer from diabetic foot complications, and among them 25% are at risk of lower limb amputations. Diabetic foot ulcers are characterized as skin lesions, gangrene, or necrosis, and may develop due to several reasons, including hyperglycemia and slower wound healing in diabetic patients. A management protocol involving wound cleaning, oral antibiotics, skin ointments, and removing dead tissue is currently followed to treat diabetic foot ulcers. In severe cases, amputation is performed to prevent the infection from spreading further. The existing therapy can be costly and present adverse side effects. Combined with a lack of vascular surgeons, this ultimately results in disability, especially in developing nations. There is a growing interest in the use of alternative therapies, such as medicinal plants, to discover more efficient and affordable treatments for diabetic foot syndrome. It has been observed that treatment with numerous plants, including Carica papaya, Annona squamosa, Catharanthus roseus, and Centella asiatica, promotes wound healing, reduces inflammation, and may decrease the number of amputations. However, little information is currently available on the prevention and management of diabetic foot ulcers, and additional research is necessary to completely understand the role of alternative therapies in the treatment of diabetic foot complications. Full article
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13 pages, 449 KiB  
Review
Management of the Diabetic Foot in People with Diabetes Mellitus Older than 65 Years
by Álvaro Astasio-Picado, Vanessa Gómez Toledano, Miriam López-Sánchez, Jesús Jurado-Palomo, Paula Cobos-Moreno and Beatriz Gómez-Martín
Appl. Sci. 2022, 12(20), 10279; https://doi.org/10.3390/app122010279 - 12 Oct 2022
Cited by 1 | Viewed by 2200
Abstract
Introduction: Diabetic foot is the infection, ulceration or destruction of the deep tissues of the foot in patients with diabetes mellitus. This pathology occurs when there are high levels of glucose in the blood, as well as other factors such as high blood [...] Read more.
Introduction: Diabetic foot is the infection, ulceration or destruction of the deep tissues of the foot in patients with diabetes mellitus. This pathology occurs when there are high levels of glucose in the blood, as well as other factors such as high blood pressure and hypercholesterolemia. These factors cause damage to the vessels and nerves, producing medium and long-term complications. This is a health problem that affects diabetic patients throughout their lives. Objective: To know the different techniques and strategies that allow to carry out an appropriate management of the diabetic foot. Methodology: A narrative review was carried out between November 2021 and July 2022 in the different databases of Pubmed (Medline), Scielo, Scopus and Web of Science (WOS), with a search string that combined the keywords derived from thesauri, namely Descriptors of Health Sciences (DeCS) and Medical Subject Headings (MeSH), combined with the Boolean operators “AND”, “NOT” and “NOT”. Results: After applying the article selection criteria and evaluating the quality of the methodology, a total of 22 articles were obtained. The results affirm the existence of promising therapies for the treatment of diabetic foot ulcers such as negative-pressure therapy and hyperbaric oxygen therapy. It is highlighted that the use of therapeutic footwear and health education are deficient aspects that must be reinforced. Conclusions: After comparing the different articles, it was possible to determine that negative-pressure therapy and hyperbaric oxygen therapy should be promoted as they are suitable for the treatment of diabetic foot ulcers. In addition, therapeutic footwear is a baseline in the diabetic foot approach. On the other hand, it is necessary to reinforce interdisciplinary work in this area and health education for patients suffering from this disease. Full article
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21 pages, 3997 KiB  
Review
Minimally Invasive Metatarsal Osteotomies (MIMOs) for the Treatment of Plantar Diabetic Forefoot Ulcers (PDFUs): A Systematic Review and Meta-Analysis with Meta-Regressions
by Carlo Biz, Elisa Belluzzi, Alberto Crimì, Nicola Luigi Bragazzi, Pietro Nicoletti, Fabiana Mori and Pietro Ruggieri
Appl. Sci. 2021, 11(20), 9628; https://doi.org/10.3390/app11209628 - 15 Oct 2021
Cited by 7 | Viewed by 2269
Abstract
Plantar Diabetic Foot Ulcers (PDFUs) are frequent injuries affecting and heavily limiting the quality of life in diabetic patients. PDFUs can be treated both conservatively (with a high recurrence rate) or surgically (with a high rate of complication). Recently, minimally invasive surgery (MIS), [...] Read more.
Plantar Diabetic Foot Ulcers (PDFUs) are frequent injuries affecting and heavily limiting the quality of life in diabetic patients. PDFUs can be treated both conservatively (with a high recurrence rate) or surgically (with a high rate of complication). Recently, minimally invasive surgery (MIS), performed by small incisions, has been increasingly applied on diabetic feet due to their encouraging outcomes and low complication rate. This systematic review with meta-analysis and meta-regression aims to evaluate for the first time the effectiveness of minimally invasive metatarsal osteotomies (MIMOs) in treating PDFUs and reducing their recurrence rate. A literature search of PubMed/MEDLINE, ISI/Web of Science and Scopus databases was carried out with the keywords “(metatarsal osteotom*) OR (metatarsal AND osteotom*) AND diabet* AND (feet OR foot OR forefoot) AND ulcer”, covering the period from 1980 until June 2021 following PRISMA guidelines. The JBI critical appraisal tool was used for Quality Assessment. Healing rate/time, infection rate, recurrence rate, non-union rate and complication rate were evaluated. When possible, these values were pooled and expressed in effect size (ES), and their 95% confidence interval (CI) was computed. Meta-regression analysis (both uni- and multivariate) was conducted. Eight studies were included in the review, including 189 patients. The healing rate of these studies ranged between 55.1 and 100%, infection rate from 3.3 to 31.8%, recurrence rate from 0.0% and 13.6% and non-union rate from 4.5–30.0%. Overall complication rate was reported in three studies and ranged from 44.9 to 68.2%. Meta-analysis of the various rates revealed an overall healing rate of 91.9% (range from 74.9 to 97.8%), infection rate of 10.9% (4.2–25.2%), recurrence rate 7.2% (3.6–14.2%), non-union rate 16.9% (10.2–26.7%) and finally, the complication rate was computed at 53.2%. Satisfactory short- to medium-term clinical and radiographic results were reported by the studies included in this review, supporting that MIMOs represent an effective surgical approach to treat PDFUs. However, poor quality in the methodology of some studies and the lack of long-term data were reported. Therefore, randomized controlled trials, prospective studies and long-term follow-up studies are needed. Full article
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Other

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7 pages, 274 KiB  
Brief Report
Self-Care Planning and Sanitary Education in the Prevention of the Diabetic Foot
by Álvaro Astasio-Picado, Paula Cobos-Moreno and Beatriz Gómez-Martín
Appl. Sci. 2021, 11(16), 7281; https://doi.org/10.3390/app11167281 - 07 Aug 2021
Cited by 2 | Viewed by 2887
Abstract
Diabetes Mellitus is the main cause of chronic patients in Spain. An equivocal exploration by the health worker and the client itself leads to the appearance of chronic complications, the most important being diabetic foot. The role of the health worker in the [...] Read more.
Diabetes Mellitus is the main cause of chronic patients in Spain. An equivocal exploration by the health worker and the client itself leads to the appearance of chronic complications, the most important being diabetic foot. The role of the health worker in the prevention and treatment of this is key. Objectives: This work has the general objective of identifying and providing information to the diabetic client about diabetic foot prevention and care elements to avoid complications. Data sources, study eligibility criteria: The search for the articles was carried out in various scientific databases with the help of a search string, which combined the keywords and Boolean operators. Study appraisal and synthesis methods: Thirty-seven papers were selected after a review of 101 articles. Results: The implementation of a health education program, in addition to performing multidisciplinary work, favors the prevention of diabetic foot ulcers and reduces the risk of amputation. Conclusions and implications of key findings: Nurses must have greater responsibility to inspire patients ‘self-efficacy by making health education programs effective. Full article
(This article belongs to the Special Issue Diabetic Foot)
31 pages, 1111 KiB  
Systematic Review
Exercise and Manual Therapy for Diabetic Peripheral Neuropathy: A Systematic Review
by Mar Hernández-Secorún, Concepción Vidal-Peracho, Sergio Márquez-Gonzalvo, Jaime Corral-de-Toro, Julián Müller-Thyssen-Uriarte, Jacobo Rodríguez-Sanz, María Orosia Lucha-López, José Miguel Tricás-Moreno and César Hidalgo-García
Appl. Sci. 2021, 11(12), 5665; https://doi.org/10.3390/app11125665 - 18 Jun 2021
Cited by 4 | Viewed by 8463
Abstract
(1) Background: Diabetic peripheral neuropathy (DPN) is one of the most common complications of diabetes mellitus (DM). Control of hyperglycaemia as well as surgical decompression are effective treatments for these patients. However, surgery is not indicated for all candidates. Manual therapy and physical [...] Read more.
(1) Background: Diabetic peripheral neuropathy (DPN) is one of the most common complications of diabetes mellitus (DM). Control of hyperglycaemia as well as surgical decompression are effective treatments for these patients. However, surgery is not indicated for all candidates. Manual therapy and physical exercise have been shown to be effective for peripheral neuropathies, and exercise for DM. The aim is to review the effectiveness of manual therapy and/or exercise in patients with DPN. (2) Methods: Randomised controlled clinical trials comparing the effects of manual therapy and/or exercise on pain, function and/or balance were selected. The search strategy was performed in PubMed, PEDro, Scopus, Cochrane and Web of Science databases. The PRISMA statement was followed. (3) Results: A total of 656 articles were registered, and 29 were selected. There was little consensus on DPN criteria selection. Aerobic, strength and balance exercises are beneficial for DPN. Sessions of 30–60 min, three times per week for 8 weeks seems to be the most used dose. Manual therapy is effective in the short term. A combination of both modalities was more beneficial than alone in one study. (4) Conclusions: Exercise and manual therapy are beneficial for patients with DPN. More studies should be carried out for analysing the potential effect of combining manual therapy and exercise. Full article
(This article belongs to the Special Issue Diabetic Foot)
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