The power of the digital flexor tenotomy: a case study

Krishna Gohil and Helen Milnes

In May 2023, the International Working Group on the Diabetic Foot (IWGDF) updated the offloading guidelines to support surgical offloading interventions. The evidence for digital tenotomy of the flexor tendon is strong, with the desirable effects reported to be moderate. This case study describes a patient with a 5-year history of apical toe ulcerations and a history of apical osteomyelitis, which were healed within 2 weeks following digital tenotomies performed in an outpatient setting. Considering the new offloading guideline, we must consider how clinicians can optimise patient care and offer this valuable treatment option to patients.

Citation: Gohil K, Milnes H (2023) The power of the digital flexor tenotomy: a case study. The Diabetic Foot Journal 26(1): 6–10

Key words

- Diabetes Related foot ulceration

- Digital flexor tenotomy

- Healing

- Surgical offloading

- WIfI

Article points

1. The International Working Group on the Diabetic Foot 2023 guidelines support digital flexor tenotomies in individuals with diabetes and callus to prevent development of ulceration or recurrent foot ulceration.

2. The cost of flexor tenotomies is low in comparison to ongoing dressings, ongoing antibiotics and potential hospital admission for infection management

3. Surgical offloading should be considered when conservative non-operative treatments have been unsuccessful.

Authors

Krishna Gohil is Senior Lecturer Podiatry/Prescribing, University of Northampton, UK; Helen Milnes is Consultant Podiatric Surgeon, University Hosptital Birmingham, UK

Pharmacological treatment of painful neuropathy in adults with diabetes

Helen O’Neil

Diabetic neuropathy is one of the most prevalent chronic complications in people living with diabetes and painful diabetic neuropathy is difficult to manage clinically. Guidelines recommend offering a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain. It is recommended that pharmacotherapy is offered in a stepwise approach to ensure tolerability and effectiveness of individual medications. Patients often do not respond to monotherapy and, therefore, combination pharmacotherapy may be required. The aim of treatment is to improve quality of life for patients living with painful diabetic neuropathy by reducing pain and promoting increased participation in all aspects of daily living.

Citation: O’Neil (2023) Pharmacological treatment of painful neuropathy in adults with diabetes. The Diabetic Foot Journal 26(1): 20–3

Key words

- Diabetic neuroarthropathy

- Neuropathic pain

- Pharmacological therapy

Article points

1. Painful diabetic neuropathy is common in people with diabetes and is difficult to manage clinically.

2. Guidelines recommend amitriptyline, duloxetine, gabapentin or pregabalin as initial pain management options.

3. Patients often do not respond to monotherapy, so combination pharmacotherapy may be required.

Author

Helen O’Neil is Senior Medicines Optimisation Pharmacist, South Tyneside and Sunderland NHS Foundation Trust, UK

Imaging in osteomyelitis and Charcot neuroarthropathy: can infrared thermography aid in diagnosis?

Gillian Harkin

Differential diagnosis between active Charcot neuroarthropathy and infection in the presence of neuropathic ulceration presents a significant challenge to the clinician. Both conditions may present as a red, hot, swollen foot with an absence of pain. Although additional tests may aid in developing a clear diagnosis these can be invasive (blood testing), carry exposure to ionising radiation (X-ray) or be difficult to access rapidly (MRI). The following case study demonstrates how infrared thermography may prove useful within the clinical environment as a diagnostic test as well as a useful educational tool to guide treatment planning in collaboration with an individual with diabetes. 

Citation: Harkin G (2023) Imaging in osteomyelitis and Charcot neuroarthropathy: can infrared thermography aid in diagnosis?. The Diabetic Foot Journal 26(1): 24–8

Key words

- Charcot neuroarthropathy

- Differential diagnosis

- Osteomyelitis

- Thermal imaging

- Ulceration

Article points

1. It can be difficult to differentiate between Charcot neuroarthropathy and osteomyelitis due to similar clinical presentations.

2. Thermal images can be used to inform discussions as part of realistic medicine

3. Thermal imaging may be helpful in identifying the origin of heat within the foot, aiding diagnosis.

Author

Gillian Harkin is Lead Clinical Podiatrist. NHS Greater Glasgow & Clyde, Glasgow, UK.

Diabetic gastroparesis

      Gastroparesis is a recognised complication of diabetes (both type 1 and type 2) and, whilst not the most commonly observed complication, it carries with it a significant impact on a person’s health, glycaemic control, social functioning and mental wellbeing. Gastroparesis is often not well recognised because of the disparate group of symptoms it may present with. Symptoms are often misattributed or not recognised, and consequently the diagnosis is either missed or delayed. It should be managed by a multidisciplinary team with knowledge of and expertise in this area. Above all, the team should be understanding and help steer patients to the best supportive care.

Author: Simon Saunders,

Clinical Lead Academic Consultant in Diabetes and Endocrinology, Mersey and West Lancashire Teaching Hospitals NHS Trust

Citation: Saunders S (2023) At a glance factsheet: Diabetic gastroparesis. Diabetes & Primary Care 25: [Early view publication]

Bilateral Charcot neuroarthropathy following successive surgical arterial revascularisation to both legs in a patient with diabetes — an interesting case history

Neil Baker and Isam Osman

An unusually good blood supply and peripheral neuropathy are reportedly accepted prerequisites for the pathogenesis of Charcot neuroarthropathy (CN) in people with diabetes. There is anecdotal evidence that CN does not occur in the presence of peripheral vascular disease. We report the first case of a person with diabetes who had revascularisation surgery performed to both legs independently, which was subsequently followed by CN in the corresponding feet. This case illustrates the importance of a good blood supply in the development of CN. Furthermore, it supports the concept that reduced arterial supply is protective against the development of CN. This case also highlights the need for regular follow-up reviews where postoperative hyperaemia is evident.

Citation: Baker N, Osman I (2023) Bilateral Charcot neuroarthropathy following successive surgical arterial revascularisation to both legs in a patient with diabetes — an interesting case history. The Diabetic Foot Journal 26(1): 36–9

Article points

1. A very good blood flow is a prerequisite for active Charcot development

2. Although this is a rare case, it is advised to be vigilant in monitoring a hot, swollen, inflamed foot and leg after vascular intervention in a patient with existing neuropathy

3. Early detection and immobilisation (cast) of active Charcot with regular follow up is imperative to facilitate optimal resolution and reduction in deformity

4. Differential diagnosis is essential in the presentation of a neuropathic red/ discoloured (dark), hot, swollen foot and leg, particularly if ulceration is present.

Authors

Neil Baker is Consultant Diabetes /Vascular Podiatrist, Sana Clinic Al Shaab Kuwait; formerly Ipswich Hospital NHS Trust; Isam Osman is Consultant Vascular Surgeon, King Saud Medical City, Riyadh, Saudi Arabia; formerly Ipswich Hospital NHS Trust;

Key words

- Charcot

- Neuropathy

- Peripheral arterial disease

- Vascular intervention

Diabetes and menopause

Metabolic changes that occur during menopause are associated with increased incidence of type 2 diabetes and its risk factors, while menopausal symptoms have a negative effect on a person’s day-to-day life, and consequently their diabetes self-management. In women who are going through menopause, effective hormone replacement therapy (HRT) can improve a wide array of cardiometabolic risk factors as well as the risk of new-onset type 2 diabetes. This factsheet covers the relationship between menopause and type 2 diabetes and provides recommendations on optimising HRT in women with diabetes.

Author: Claire Partridge, RGN, MSc Health Sciences (Diabetes)

Citation: Partridge C (2023) At a glance factsheet: Diabetes and menopause. Diabetes & Primary Care 25: [Early view publication]