Can Probiotics Facilitate Healing Of Diabetic Foot Ulcers?

A new study concludes that supplementation with probiotics can help decrease the size of diabetic foot ulcers.

The study, published in Diabetes Metabolism Research and Reviews, involved 60 patients with Wagner grade 3 diabetic foot ulcers, who received either probiotics or placebo. The authors found that probiotics significantly reduced ulcer length (-1.3 cm in comparison to -0.8 for placebo), width (-1.1 cm in comparison to -0.7 for placebo) and depth (-0.5 cm in comparison to -0.3 cm for placebo) over a 12-week period. Probiotics also had positive effects on patients’ fasting plasma glucose, serum insulin concentrations and HbA1c, according to the study.

Jakob Thorud, DPM, FACFAS, says the researchers’ results are promising and that probiotics may have a larger role in treating diabetes and not just diabetic foot ulcers. However, he says the study’s conclusion of a reduction in HbA1c seems to be a more plausible explanation to ulcer size reduction in line with other recent studies.

“Thus, I remain skeptical that the probiotics may be really treating glycemic control and in turn improving ulceration characteristics,” says Dr. Thorud, who is affiliated with Mercy Health System in Illinois. “If probiotics become a more mainstream adjunctive measure for diabetes, this may become a moot point.”

Matthew Regulski, DPM, does not know of scientific evidence that shows how probiotics affect perturbations in the chronic wound molecular and biochemical enviroment. As he notes, the consternation lies in exactly which bacteria are beneficial, what probiotic concentration is optimal and determining the optimal dosing schedule.

However, Dr. Regulski notes there are chronic inflammatory diseases that can have a significant contribution from overgrowth of inflammatory bacteria especially in the gut. Chronic inflammation will induce edema and vasodilation, which are avenues that bacteria can use to escape into the systemic circulation and release their inflammatory proteins to exert their deleterious effects, notes Dr. Regulski, the Director of the Wound Institute of Ocean County, NJ. He says there are some small studies in the diabetic population that show reduction of inflammatory markers with the use of probiotics but notes a need for larger, more controlled studies.

Dr. Thorud emphasizes that both the treating physician for the patient’s diabetes and the patient should be aware before prescribing probiotics that blood sugars may decrease with probiotic supplementation. He notes that patients who are using probiotics as well as antibiotics may not only benefit with a possible impact on wound healing but there may also be a moderate reduction in rates of Clostridium difficile.

Dr. Thorud already recommends that patients using antibiotics in the long term should use probiotics.

For further reading, see the April 2015 DPM Blog “Why Studying Microbiomes May Help In The Treatment of Diabetic Neuropathy” by Stephen Barrett, DPM, FACFAS at https://www.podiatrytoday.com/blogged/why-studying-microbiomes-may-help-treatment-diabetic-neuropathy .

Can A Minimally Invasive Distal Metatarsal Diaphyseal Osteotomy Treat Chronic Plantar DFUs?

By Brian McCurdy, Managing Editor

The minimally invasive distal metatarsal diaphyseal osteotomy can effectively treat chronic plantar diabetic foot ulcers by reducing plantar pressure under the metatarsal heads, according to a new study in Foot and Ankle International.

The study focused on 35 chronic plantar diabetic foot ulcers in 30 patients. Researchers note the ulcers had a mean diameter of 16.3 mm and had been present a mean of 10.3 moths. The study authors found a mean healing time of 7.9 weeks in all ulcers and note that American Orthopaedic Foot and Ankle (AOFAS) scores improved 55.3 to 81.4 points after surgery. At a mean follow-up of 25.3 months, the authors found no recurring ulcers and few complications.

J. Monroe Laborde, MD, uses tendon balancing first to reduce plantar pressure in diabetic foot ulcers and calls the technique more effective and quicker than other techniques in lowering plantar pressure. He also notes that tendon balancing can best prevent ulcer recurrence and transfer ulcers, and is the least demanding in terms of post-op patient adherence.

Dr. Laborde, a Clinical Assistant Professor of Orthopaedic Surgery and the Director of the Foot Clinic at Louisiana State University Health Sciences Center in New Orleans, uses toe tenotomy for toe ulcers, and gastrocsoleus recession for forefoot and midfoot ulcers. He adds posterior tibial lengthening for fifth metatarsal ulcers, peroneus longus lengthening for first metatarsal ulcers and percutaneous exostectomy for midfoot ulcers. Dr. Laborde never uses total contact casting (TCC). In his experience, Dr. Laborde has found that TCC is less effective at healing with higher complications and does not prevent ulcer recurrence.

In Dr. Laborde’s experience, metatarsal osteotomy leads to more transfer ulcers and local complications in patients without pedal pulses, smokers, patients with foot infections and gangrene. He only uses osteotomy for diabetic foot ulcers in rare failures of tendon balancing.

Study Examines Link Between Hallux Valgus And An Accessory Tendon Of The Extensor Hallucis Longus Muscle

By Brian McCurdy, Managing Editor

A recent study in Surgical and Radiologic Anatomy finds a high occurrence of hallux valgus deformity in feet with the anatomic variant of accessory tendon of the extensor hallucis longus muscle.

In the study involving 98 female adult cadaveric feet, researchers measured hallux valgus and intermetatarsal angles, and compared them to the relative angle between the primary extensor hallucis longus tendon and accessory tendon, and the length of the accessory tendon. The study authors found the accessory tendon to be present in 26.5 percent of feet and hallux valgus was present in 36.7 percent of all feet. The researchers also note a 65.4 percent prevalence of hallux valgus deformity in feet with an accessory tendon, but add that there was no significant correlation between accessory tendon morphological characteristics and the cadavers’ age or the hallux valgus angle and intermetatarsal angle.

Neal Blitz, DPM, FACFAS, notes surgeons commonly encounter an accessory tendon when performing bunion surgery, and he agrees that an accessory tendon is present in approximately two-thirds of cases of hallux valgus.

“The accessory tendon is something that the bunion surgeon rarely thinks about because it is a such a flimsy, vestigial-like tendon and appears to do almost nothing,” says Dr. Blitz, who is in private practice in both Midtown Manhattan, New York, and in Beverly Hills, Calif. 

If the accessory tendon was lateral to the extensor tendon, Dr. Blitz says one could theorize that the accessory tendon was pulling the hallux laterally, promoting bunion formation. However, he notes the accessory tendon is a medial structure and perhaps the accessory tendon’s function is to try to counteract formation of hallux valgus since it is present more commonly in feet with bunions. Since bunions are genetic in about half of the cases, Dr. Blitz suggests that the accessory tendon may be passed on along with the bunion.

Dr. Blitz says future studies might examine if any correlation exists between accessory tendon presence and metatarsal head shape. 

In Brief

The American Board of Multiple Specialties in Podiatry (ABMSP) is offering non-exam board certification in geriatric podiatry. The ABMSP says the certification is for applicants demonstrating qualifications through an elevated portfolio of experience and service. The new certification is a response to an increasing need for geriatric-centered podiatric care, according to the ABMSP.