The Diabetic Foot

Aristidis Veves MD, Rongxiang Xu, MD, Professor of Surgery, Harvard Medical School, Director, The Rongxiang Xu, MD, Center for Regenerative Therapeutics, Research Director, Joslin-Beth Israel Deaconess Foot Center, Beth Israel Deaconess Medical Center One Deaconess Road, Palmer 321A, Boston, MA 02215, USA

John M. Giurini, DPM, Associate Professor of Surgery, Harvard Medical School, Co-director, Joslin-Beth Israel Deaconess Foot Center, Consultant, Joslin Diabetes Center, Chief, Division of Podiatry, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA

Marc L. Schermerhorn, MD, George H.A. Clowes, Jr. Professor of Surgery, Harvard Medical School Chief, Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, 110 Francis Street, Suite 5B, Boston, MA 02215, USA.

Clinical Features and Diagnosis.-Burden of Diabetic Foot.- Incidence, prevalence of foot ulceration.- Cost of foot ulceration.- The clinical examination of the diabetic foot and the identification of the at risk patient.- Clinical examination.- Screening techniques.- Classification of ulcers (Wagner and Texas classification and others in brief).- (omit vascular examination).- Diabetic neuropathy.- Epidemiology.- Classification.- Clinical features, main emphasis on sensorimotor neuropathy or other neuropathies of lower extremity.- Differential diagnosis.- Treatment.- Clinical features and diagnosis of peripheral arterial disease.- Pathogenesis.- Clinical features.- Diagnostic criteria.- Non-invasive methods, TcPO2, ABI.- Invasive methods.- Proposed algorithm, Reference to the ADA Consensus statement and PAD statement.- Radiographic changes of the diabetic foot.- Plain x-rays.- MRI.- Osteomyelitis diagnosis.- Differential diagnosis of osteomyelitis and Charcot.- MRI spectroscopy.- Principles of care in the diabetic surgical patient.- Control of DM in the surgical patient.- Role of intensive treatment.- Pathophysiology.- Pathophysiology of wound healing in chronic wounds.- Physiology of wound healing.- Pathophysiology of wound healing in DM.- Role of inflammation.- Role of angiogenesis under normal conditions.- Angiogenesis and Diabetes.- Pathophysiology of angiogenesis in the healing of the diabetic foot ulcer.- Factors that Affect Diabetic Wound Healing.- Neuropeptides and wound healing.- Mast cells.- PTP1B in wound healing.- Animal data vs human data: Similarities and differences.- Mechanisms of Vascular Disease in Diabetes.- Micro vs macrocirculation.- PAD in diabetes.- Role of microcirculation.- Omics, their role in understanding the diabetic lower extremity pathophysiology.- Skin Changes in the Diabetic Foot.- Dermatologic conditions Inflammation.- Biomechanics of the diabetic foot.- Foot anatomy related to biomechanics.- Gait Cycle.- Changes in diabetes (LJM, high foot pressures).- Balance in diabetes.- Development of foot ulceration.- Methods to measure foot pressures.- Out of shoe methods.- In shoe methods.- Foot pressure measurements in diabetes.- Cell Therapies: New Frontier for the Management of Diabetic Foot Ulceration.- Limitations of currently available treatments.- Emerging new concepts.- Role of extracellular vesicles, modified mRNA, miRNA and siRNA in diabetic lower extremity complications.- New Biomaterials for the Management of the Diabetic Lower Extremity.- Microbiota of diabetic lower extremity.- Wound infection in diabetes.- Biomarkers of DFU and its healing progress.- Animal models of DFU.- Management of the Diabetic Foot.- Microbiology and Treatment of Diabetic Foot Infection.- Microbiology.- Algorithm of treatment.- Topical vs systemic treatment DFU assessment and wound preparation.- Topical Wound Care Treatment and indications for their use.- Role of dressings.- Selection of dressings, evidence-based evaluation.- Principles for using growth factors.- Review of tested all growth factors so far.- Review of VEGF and PDGF gene therapy clinical trials.- Emphasis on Regranex, the only commercially available growth factor:  review of data, indications for using it in clinical practice.- Treatment according to ulcer stages.- Description of different LSE currently in clinical trials or available in clinical practice.- Review of data regarding diabetic foot studies.- Description of other topical, biologically active products.- Surgical Treatment of the Ulcerated Foot.- Lower Extremity Arterial Reconstruction in Patients with Diabetes Mellitus: Principles of Treatment.- Principles of treatment.- Brief description of surgical methods.- Outcomes of surgery.- Indications for angioplasty.- Brief description of angioplasty methods.- Outcomes of angioplasty.- Recommendations by recent guidelines.- We need numerous figures and pictures.- Reconstruction of the diabetic foot.- Reconstruction of diabetic foot.- Reconstruction of soft tissues of the Charcot foot.- Role of dermatomes.- Charcot Arthropathy in the Diabetic Foot.- Epidemiology.- Pathophysiology, stages of disease.- Microcirculation and development of Charcot.- Radiology.- Treatment.- Amputations and rehabilitation.- Major amputations, indications and description of basic principles.- Principles of rehabilitation.- Prostheses.- Organization and Preventive Care.- Organizationof the Diabetic Foot Care team.- Description of the DF care team.- Role of each specialty.- Flow diagram (gate keeper, communication between teams etc).- Quality of Care.- Briefly describe current concepts of quality of care.- Quality of care of DF.- Comparative effectiveness.- Education and behavior modification at the at risk patient.- Psychological profile of the patient with DFU.- Impact of DFU on quality of life.- Techniques to modify behavior.- The role of foot wear in the prevention of diabetic foot problems.- Why we need proper footwear.- Review of studies regarding footwear.- General clinical recommendations.