HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Erratum (v24,p1509) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Armstrong, D. G. Articles by Harkless, L. B. Search for Related Content PubMed PubMed Citation Articles by Armstrong, D. G. Articles by Harkless, L. B. Social Bookmarking                What's this?

Off-Loading the Diabetic Foot Wound

A randomized clinical trial

¹ Audie L. Murphy Veterans Affairs Medical Center, Tucson, Arizona
² Department of Orthopaedics, University of Texas Health Science Center, San Antonio, Texas
³ Department of Medicine, Manchester Royal Infirmary, University of Manchester, Manchester, U.K.
⁴ Department of Surgery, Southern Arizona Veterans Affairs Medical Center, Tucson, Arizona

	ABSTRACT

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 
OBJECTIVE—To compare the effectiveness of total-contact casts (TCCs), removable cast walkers (RCWs), and half-shoes to heal neuropathic foot ulcerations in individuals with diabetes.

RESEARCH DESIGN AND METHODS—In this prospective clinical trial, 63 patients with superficial noninfected, nonischemic diabetic plantar foot ulcers were randomized to one of three off-loading modalities: TCC, half-shoe, or RCW. Outcomes were assessed at wound healing or at 12 weeks, whichever came first. Primary outcome measures included proportion of complete wound healing at 12 weeks and activity (defined as steps per day).

RESULTS—The proportions of healing for patients treated with TCC, RCW, and half-shoe were 89.5, 65.0, and 58.3%, respectively. A significantly higher proportion of patients were healed by 12 weeks in the TCC group when compared with the two other modalities (89.5 vs. 61.4%, P = 0.026, odds ratio 5.4, 95% CI 1.1–26.1). There was also a significant difference in survival distribution (time to healing) between patients treated with a TCC and both an RCW (P = 0.033) and half-shoe (P = 0.012). Patients were significantly less active in the TCC (600.1 ± 320.0 daily steps) compared with the half-shoe (1,461.8 ± 1,452.3 daily steps, P = 0.04). There was no significant difference in the average number of steps between the TCC and the RCW (767.6 ± 563.3 daily steps, P = 0.67) or the RCW and the half-shoe (P = 0.15).

CONCLUSIONS—The TCC seems to heal a higher proportion of wounds in a shorter amount of time than two other widely used off-loading modalities, the RCW and the half-shoe.

Abbreviations: RCW, removable cast walker • TCC, total-contact cast • TcPO₂, transcutaneous oximetry

	INTRODUCTION

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 
Neuropathic ulcers are the prime precipitant of diabetes-related amputations of the lower extremity (1). The central goal of any treatment program designed to heal these wounds is effective reduction in pressure (off-loading) (2). Total-contact casts (TCCs) are considered the gold standard of ulcer treatment by many experts in this field (345678910111213141516). This assertion, however, has been made ostensibly without any meaningful side-by-side comparison of devices. Our and other investigators’ systematic reviews have been unable to identify any studies that prospectively compare the clinical effectiveness of various prosthetic devices with off-load ulcer sites to facilitate wound healing (17). Therefore, the purpose of this study was to compare the effectiveness of TCCs, removable cast walkers (RCWs), and half-shoes to heal neuropathic foot ulcerations in individuals with diabetes.

	RESEARCH DESIGN AND METHODS

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 
In this prospective clinical trial, 63 patients were randomized into one of three off-loading modalities, including TCC, half-shoe (Darco, Huntington, WV), or the Aircast diabetic walker (Aircast, Summit, NJ). The diagnosis of diabetes had been made before enrollment and was confirmed either by communication with primary care providers or by reviewing medical records. All patients had clinically significant loss of protective sensation (>25 V) as measured with a biothesiometer (Biomedical Instrument, Newbury, OH) (18,19), at least one palpable foot pulse or a transcutaneous oximetry (TcPO₂) measurement higher than 40 mmHg at the level of the dorsum of the forefoot, and a neuropathic plantar diabetic foot ulcer corresponding to grade 1A (superficial, not extending to tendon, capsule, or bone using the University of Texas Diabetic Foot Wound Classification System) (20). Neuropathy was defined as the inability to sense the 10-g Semmes-Weinstein monofilament and a vibration perception threshold >25 V (18,19,21). Patients who had active infection, were unable to walk without wheelchair assistance, had wounds in locations on the heel, rear foot, or area other than the plantar aspect of the foot, or had severe peripheral vascular disease (diagnosed by the criteria listed above) were excluded from the study. If patients had more than one plantar wound, the largest wound was used as the index ulcer for inclusion in this study.

Patients were randomized through a computerized randomization schedule. Randomization was performed after the initial screening. The clinical study protocols and the informed consent that each patient was required to sign were approved by the appropriate Institutional Review Board. TCCs were applied using a modification of the technique described by Kominsky (22). The modification to this technique included the use of a cast boot in lieu of the rubber cast walker and plywood platform. TCCs were changed on a weekly basis or as clinically necessary. RCWs and half-shoes were applied using the directions dispensed with the original packaging. All patients were instructed to use the devices at all times during ambulation.

All patients were followed on a weekly basis for device inspection, wound care, and wound debridement. All wounds were surgically debrided as required on each visit. Wounds were measured using a computerized planimetric video wound measurement system (23). Patients were instructed to wear a pedometer (Sportline, Campbell, CA), which was calibrated upon initiation of the study, as a general measure of activity. The total number of steps was recorded on each visit by study personnel.

Outcomes were assessed at wound healing (defined as complete epithelialization) or at 12 weeks, whichever came first. Primary outcome measures included proportion of complete wound healing at 12 weeks and activity (defined as steps per day). Of an initial enrollment pool of 75 patients, 12 failed to complete the course of study. Reasons for this included discomfort (four TCC, three RCW), instability (one half-shoe), or failure to return for follow-up appointments and data-collection visits (two TCC, two RCW).

We used an analysis of variance with Tamhane’s post-hoc test for multiple comparisons to evaluate all continuous variables between off-loading groups. We evaluated the effect of continuous variables on healing in general using a Mann-Whitney U test. Dichotomous variables were evaluated with a ² test with odds ratio and 95% CI. To evaluate the healing characteristics of each device as a function of weeks of therapy and mean time to closure among patients healing within the 12-week study period, we used a Kaplan-Meier life-table analysis (log-rank test). Using the above analyses, a difference of 40% between any two arms could be detected with a sample size of 60 yielding a power exceeding 80%. For all analyses, we used an of 0.05.

	RESULTS

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 
Descriptive characteristics for the subgroups are listed in Table 1. No significant differences were observed in any of the characteristics evaluated, including age, sex, duration of diabetes, size or location of wounds, or duration of plantar wounds. With the numbers available, we could not detect a difference in wound healing based on sex (P = 0.15) or degree of glucose control (P = 0.78). However, healed wounds were smaller at baseline than unhealed wounds (1.1 ± 1.0 vs. 1.9 ± 1.3 cm², P = 0.02).

View larger version (18K): [in this window] [in a new window]   Figure 1 — A significant difference in cumulative wound survival was noted at 12 weeks between patients treated with a TCC half-shoe and a RCW (Aircast). P = 0.012 and 0.033, respectively.

	CONCLUSIONS

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 
The results of this study suggest that the TCC heals a higher proportion of wounds in a shorter amount of time than two other widely used off-loading modalities, the RCW and the half-shoe. Additionally, it seems that patients are less active when treated with the TCC than with the half-shoe. This reduction in activity and ability to aggressively off-load the plantar aspect of the foot may partially explain the success of the TCC. To our knowledge, this is the first randomized clinical trial in the medical literature examining the clinical effectiveness of these modalities.

As noted earlier, TCCs are considered by most diabetic foot specialists to be the gold standard off-loading modality for treatment of wounds on the sole of the foot (3). The technique has come to be known as total-contact casting because it involves a molded and minimally padded cast that maintains contact with the entire plantar aspect of the foot and the lower leg. Total-contact casting has been frequently reported as effective in treating noninfected, nonischemic plantar diabetic foot wounds, with proportions of healing ranging from 72 to 100% in times ranging from 1 month to several weeks (5,7–9,12,13,15,16). Generally, peak plantar pressures are highest in the forefoot, whereas they tend to be of a lower magnitude in the rearfoot and medial arch. Shaw et al. (24), and later Armstrong and Stacpoole-Shea (25), noted that a large proportion of the pressure reduction realized in the forefoot with the TCC is transmitted along the cast wall or to the rearfoot.

TCCs are effective for a number of reasons in addition to their ability to mitigate pressure. They may help reduce or control edema and potentially protect the foot from infection (10). However, the most important attribute of the TCC may be its ability to "force compliance." The patient has little choice other than to adhere to the regimen prescribed by the clinician, because the device is not easily removable. Furthermore, based on the results of the present study, it seems that the TCC may significantly curtail activity, thereby reducing the number of cycles of repetitive stress on an already open wound. It should be noted in this study that patients were relied upon to wear the pedometers just as they were relied upon to wear the off-loading devices. Ideally, we could use an activity monitor that was less reliant on patient compliance.

Lavery et al. (14) reported that there was not a practically appreciable difference between some RCWs (such as the Aircast) and TCC with respect to ability to off-load the plantar aspect of the foot. However, the present study suggests that a higher prevalence of healing exists in patients treated with TCCs. When discussing a removable device, it is perhaps the removability that is its biggest detriment. Perhaps two additional variables that should be added to the equation leading to device selection should be level of activity and compliance of the patient.

The above-described advantages make the TCC an attractive choice to off-load the diabetic foot ulcer. However, there are a number of potential negative detractors that may dissuade some clinicians from using this modality. Most clinics or practices do not have a physician or cast technician with training or experience to safely apply a TCC. Because improper cast application can cause skin irritation and, in some cases, even frank ulceration, which can be a most unappealing characteristic. In addition, TCCs do not allow patients, family members, or health-care providers to assess the foot or wound on a daily basis. Therefore, advanced wound healing modalities that require daily applications may not be suitable for use with patients using a nonremovable device such as the TCC. Additionally, many patients experience problems with activities of daily living, such as bathing and sleeping. Also, certain designs of TCCs may exacerbate postural instability (26). Finally, TCCs generally are contraindicated for wounds with soft-tissue infections or osteomyelitis. Any one of the above reasons may compel the clinician to elect to use devices other than the TCC for off-loading the wound for a given patient. Additionally, one may argue that upfront costs for treatment of wounds with a TCC are higher. The general cost in materials alone for a TCC is approximately $50–75. When multiplied by the cost of each subsequent cast change (generally at least weekly for the duration of the wound), this can certainly exceed the $150–200 for the RCW and $25–75 for accommodative sandals such as the half-shoe. However, one may argue that a significantly faster healing time would negate the added cost in supplies. Clearly, this issue requires further study.

In conclusion, this study suggests that there are significant differences in wound healing based on the off-loading device selected. The central tenets of healing the noninfected, nonischemic diabetic wound have and will continue to be appropriate debridement and pressure reduction. There is no single off-loading device that is appropriate for every patient. It is for this reason that we hope that work will continue in this area to assess various treatments to provide the clinician with the evidence necessary to make informed treatment decisions. It is in this manner that we believe we may realize more consistent wound healing and, commensurately, a meaningful and widespread reduction in the rate of amputations of the lower extremity.

	ACKNOWLEDGMENTS

 
This study was funded by the U.S. Department of Veterans Affairs’ Rehabilitation R&D Merit Award Grant A2150RC and the Aircast Research Foundation.

	FOOTNOTES

 
Address correspondence and reprint requests to David G. Armstrong, Department of Surgery, Southern Arizona Veterans Affairs Medical Center, 3601 South Sixth Ave., Tucson, AZ 85723. E-mail: armstrong{at}usa.net.

Received for publication 28 November 2000 and accepted in revised form 26 January 2001.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

	References

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 

1. Pecoraro RE, Reiber GE, Burgess EM: Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 13:513–521, 1990[Abstract]
   
2. Armstrong DG, Lavery LA: Evidence-based options for off-loading diabetic wounds. Clin Podiatr Med Surg 15:95–104, 1998[Medline]
   
3. American Diabetes Association: Consensus Development Conference on Diabetic Foot Wound Care. Diabetes Care 22:1354–1360, 1999[Medline]
   
4. Coleman W, Brand PW, Birke JA: The total contact cast, a therapy for plantar ulceration on insensitive feet. J Am Podiatr Med Assoc 74:548–552, 1984
   
5. Helm PA, Walker SC, Pulliam G: Total contact casting in diabetic patients with neuropathic foot ulcerations. Arch Phys Med Rehabil 65:691–693, 1984[Medline]
   
6. Baker RE: Total contact casting. J Am Podiatr Med Assoc 85:172–176, 1995[Abstract]
   
7. Sinacore DR, Mueller MJ, Diamond JE: Diabetic plantar ulcers treated by total contact casting. Phys Ther 67:1543–1547, 1987
   
8. Myerson M, Papa J, Eaton K, Wilson K: The total contact cast for management of neuropathic plantar ulceration of the foot. J Bone Joint Surg 74A:261–269, 1992[Abstract/Free Full Text]
   
9. Walker SC, Helm PA, Pulliam G: Chronic diabetic neuropathic foot ulcerations and total contact casting: healing effectiveness and outcome probability (Abstract). Arch Phys Med Rehabil 66:574, 1985
   
10. Mueller MJ, Diamond JE, Sinacore DR, Delitto A, Blair VPD, Drury DA, Rose SJ: Total contact casting in treatment of diabetic plantar ulcers: controlled clinical trial. Diabetes Care 12:384–388, 1989[Abstract]
    
11. Liang PW, Cogley DI, Klenerman L: Neuropathic ulcers treated by total contact casts. J Bone Joint Surg 74B:133–136, 1991[Free Full Text]
    
12. Walker SC, Helm PA, Pulliam G: Total contact casting and chronic diabetic neuropathic foot ulcerations: healing rates by wound location. Arch Phys Med Rehabil 68:217–221, 1987[Medline]
    
13. Armstrong DG, Lavery LA, Bushman TR: Peak foot pressures influence the healing time of diabetic foot ulcers treated with total contact casts. J Rehabil Res Dev 35:1–5, 1998[Medline]
    
14. Lavery LA, Vela SA, Lavery DC, Quebedeaux TL: Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulcerations: a comparison of treatments. Diabetes Care 19:818–821, 1996[Abstract]
    
15. Lavery LA, Armstrong DG, Walker SC: Healing rates of diabetic foot ulcers associated with midfoot fracture due to Charcot’s arthropathy. Diabet Med 14:46–49, 1997[Medline]
    
16. Lavery LA, Vela SA, Lavery DC, Quebedeaux TL: Total contact casts: pressure reduction at ulcer sites and the effect on the contralateral foot. Arch Phys Med Rehabil 78:1268–1271, 1997[Medline]
    
17. Spencer S: Pressure relieving interventions for preventing and treating diabetic foot ulcers (Cochrane review) [In Process Citation]. Cochrane Database Syst Rev 3, 2000
    
18. Young MJ, Breddy JL, Veves A, Boulton AJ: The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds: a prospective study. Diabetes Care 17:557–560, 1994[Abstract]
    
19. Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli JG: Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Arch Intern Med 158:289–292, 1998[Abstract/Free Full Text]
    
20. Armstrong DG, Lavery LA, Harkless LB: Validation of a diabetic wound classification system: the contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 21:855–859, 1998[Abstract]
    
21. Young MJ, Boulton AJ, MacLeod AF, Williams DR, Sonksen PH: A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population. Diabetologia 36:150–154, 1993[Medline]
    
22. Kominsky SJ: The ambulatory total contact cast. In The High Risk Foot in Diabetes Mellitus. 1st ed. RG Frykberg, Ed. New York, Churchill Livingstone, 1991, p. 449–455
    
23. Wunderlich RP, Peters EJ, Armstrong DG, Lavery LA: Reliability of digital videometry and acetate tracing in measuring the surface area of cutaneous wounds. Diabetes Res Clin Pract 49:87–92, 2000[Medline]
    
24. Shaw JE, Hsi WL, Ulbrecht JS, Norkitis A, Becker MB, Cavanagh PR: The mechanism of plantar unloading in total contact casts: implications for design and clinical use. Foot Ankle Int 18:809–817, 1997[Medline]
    
25. Armstrong DG, Stacpoole-Shea S: Total contact casts and removable cast walkers: mitigation of plantar heel pressure. J Am Podiatr Med Assoc 89:50–53, 1999[Abstract]
    
26. Lavery LA, Fleishli JG, Laughlin TJ, Vela SA, Lavery DC, Armstrong DG: Is postural instability exacerbated by off-loading devices in high risk diabetics with foot ulcers? Ostomy Wound Management 44:26–34, 1998
    

CiteULike

Del.icio.us

Digg

Reddit

Technorati

This article has been cited by other articles:

				R. C. Marx and M. S. Mizel What's New in Foot and Ankle Surgery J. Bone Joint Surg. Am., November 1, 2008; 90(11): 2546 - 2546. [Full Text] [PDF]

				M.P. Khanolkar, S.C. Bain, and J.W. Stephens The diabetic foot QJM, September 1, 2008; 101(9): 685 - 695. [Abstract] [Full Text] [PDF]

				E. E. Klein, R. T. Crews, S. C. Wu, J. S. Wrobel, and D. G. Armstrong CLEAR Cleat: A Proof-of-Concept Trial of an Aerobic Activity Facilitator to Reduce Plantar Forefoot Pressures and Their Potential in Those with Foot Ulcers J Am Podiatr Med Assoc, July 1, 2008; 98(4): 261 - 267. [Abstract] [Full Text] [PDF]

				B. Perrin and H. Swerissen The Behavior and Psychological Functioning of People at High Risk of Diabetes-Related Foot Complications The Diabetes Educator, May 1, 2008; 34(3): 493 - 500. [Abstract] [Full Text] [PDF]

				C. Caravaggi, A. Sganzaroli, M. Fabbi, P. Cavaiani, I. Pogliaghi, R. Ferraresi, F. Capello, and A. Morabito Nonwindowed Nonremovable Fiberglass Off-Loading Cast Versus Removable Pneumatic Cast (AircastXP Diabetic Walker) in the Treatment of Neuropathic Noninfected Plantar Ulcers: A randomized prospective trial Diabetes Care, October 1, 2007; 30(10): 2577 - 2578. [Full Text] [PDF]

				A. Piaggesi, S. Macchiarini, L. Rizzo, F. Palumbo, A. Tedeschi, L. A. Nobili, E. Leporati, V. Scire, I. Teobaldi, and S. Del Prato An Off-the-Shelf Instant Contact Casting Device for the Management of Diabetic Foot Ulcers: A randomized prospective trial versus traditional fiberglass cast Diabetes Care, March 1, 2007; 30(3): 586 - 590. [Abstract] [Full Text] [PDF]

				S. Beckert, M. Witte, C. Wicke, A. Konigsrainer, and S. Coerper A New Wound-Based Severity Score for Diabetic Foot Ulcers: A prospective analysis of 1,000 patients Diabetes Care, May 1, 2006; 29(5): 988 - 992. [Abstract] [Full Text] [PDF]

				V. Dini, M. Romanelli, A. Piaggesi, A. Stefani, and F. Mosca Cutaneous tissue engineering and lower extremity wounds (part 2). International Journal of Lower Extremity Wounds, March 1, 2006; 5(1): 27 - 34. [Abstract] [PDF]

				B. B. Pua, B. E. Muhs, T. Maldonado, E. Ben-Arie, P. Sheehan, and P. J. Gagne Total-Contact Casting as an Adjunct to Promote Healing of Pressure Ulcers in Amputees Vascular and Endovascular Surgery, March 1, 2006; 40(2): 135 - 140. [Abstract] [PDF]

				A. P. Garrow, C. H.M. van Schie, and A. J.M. Boulton Efficacy of Multilayered Hosiery in Reducing In-Shoe Plantar Foot Pressure in High-Risk Patients With Diabetes Diabetes Care, August 1, 2005; 28(8): 2001 - 2006. [Abstract] [Full Text] [PDF]

				D. G. Armstrong, M. A. Rosales, and A. Gashi Efficacy of Fifth Metatarsal Head Resection for Treatment of Chronic Diabetic Foot Ulceration J Am Podiatr Med Assoc, July 1, 2005; 95(4): 353 - 356. [Abstract] [Full Text] [PDF]

				M. A. Ansari and V. K. Shukla Foot Infections International Journal of Lower Extremity Wounds, June 1, 2005; 4(2): 74 - 87. [Abstract] [PDF]

				M. H. Nabuurs-Franssen, M. S.P. Huijberts, R. Sleegers, and N. C. Schaper Casting of Recurrent Diabetic Foot Ulcers: Effective and safe? Diabetes Care, June 1, 2005; 28(6): 1493 - 1494. [Full Text] [PDF]

				M. Petre, P. Tokar, D. Kostar, and P. R. Cavanagh Revisiting the Total Contact Cast: Maximizing off-loading by wound isolation Diabetes Care, April 1, 2005; 28(4): 929 - 930. [Full Text] [PDF]

				D. G. Armstrong, M. B. Sangalang, D. Jolley, F. Maben, H. R. Kimbriel, B. P. Nixon, and I. K. Cohen Cooling the Foot to Prevent Diabetic Foot Wounds: A Proof-of-Concept Trial J Am Podiatr Med Assoc, March 1, 2005; 95(2): 103 - 107. [Abstract] [Full Text] [PDF]

				B. A. Lipsky, A. R. Berendt, H. G. Deery, J. M. Embil, W. S. Joseph, A. W. Karchmer, J. L. LeFrock, D. P. Lew, J. T. Mader, C. Norden, et al. Diagnosis and Treatment of Diabetic Foot Infections J Am Podiatr Med Assoc, March 1, 2005; 95(2): 183 - 210. [Full Text] [PDF]

				D. G. Armstrong, L. A. Lavery, S. Wu, and A. J.M. Boulton Evaluation of Removable and Irremovable Cast Walkers in the Healing of Diabetic Foot Wounds: A randomized controlled trial Diabetes Care, March 1, 2005; 28(3): 551 - 554. [Abstract] [Full Text] [PDF]

				I. A. Katz, A. Harlan, B. Miranda-Palma, L. Prieto-Sanchez, D. G. Armstrong, J. H. Bowker, M. S. Mizel, and A. J.M. Boulton A Randomized Trial of Two Irremovable Off-Loading Devices in the Management of Plantar Neuropathic Diabetic Foot Ulcers Diabetes Care, March 1, 2005; 28(3): 555 - 559. [Abstract] [Full Text] [PDF]

				M. H. Nabuurs-Franssen, R. Sleegers, M. S. Huijberts, W. Wijnen, A. P. Sanders, G. Walenkamp, and N. C. Schaper Total Contact Casting of the Diabetic Foot in Daily Practice: A prospective follow-up study Diabetes Care, February 1, 2005; 28(2): 243 - 247. [Abstract] [Full Text] [PDF]

				G. B Salsich, M. J Mueller, M. K. Hastings, D. R Sinacore, M. J Strube, and J. E Johnson Effect of Achilles Tendon Lengthening on Ankle Muscle Performance in People With Diabetes Mellitus and a Neuropathic Plantar Ulcer Physical Therapy, January 1, 2005; 85(1): 34 - 43. [Abstract] [Full Text] [PDF]

				D. G. Armstrong and A. J. M. Boulton Pressure Offloading and "Advanced" Wound Healing: Isn't It Finally Time for an Arranged Marriage? International Journal of Lower Extremity Wounds, December 1, 2004; 3(4): 184 - 187. [PDF]

				A. J.M. Boulton, R. S. Kirsner, and L. Vileikyte Neuropathic Diabetic Foot Ulcers N. Engl. J. Med., July 1, 2004; 351(1): 48 - 55. [Full Text] [PDF]

				S. T.M. Krishnan, N. R. Baker, A. L. Carrington, and G. Rayman Comparative Roles of Microvascular and Nerve Function in Foot Ulceration in Type 2 Diabetes Diabetes Care, June 1, 2004; 27(6): 1343 - 1348. [Abstract] [Full Text] [PDF]

				Z. T. Bloomgarden Diabetes Complications Diabetes Care, June 1, 2004; 27(6): 1506 - 1514. [Full Text] [PDF]

				D. G. Armstrong and L. A. Lavery Decreasing Foot Pressures While Implementing Topical Negative Pressure (Vacuum-Assisted Closure) Therapy International Journal of Lower Extremity Wounds, March 1, 2004; 3(1): 12 - 15. [Abstract] [PDF]

				M. J. Jannink, H. van Dijk, J. de Vries, J. W Groothoff, and G. J Lankhorst A systematic review of the methodological quality and extent to which evaluation studies measure the usability of orthopaedic shoes Clinical Rehabilitation, January 1, 2004; 18(1): 15 - 26. [Abstract] [PDF]

				A. Piaggesi, P. Viacava, L. Rizzo, G. Naccarato, F. Baccetti, M. Romanelli, V. Zampa, and S. Del Prato Semiquantitative Analysis of the Histopathological Features of the Neuropathic Foot Ulcer: Effects of pressure relief Diabetes Care, November 1, 2003; 26(11): 3123 - 3128. [Abstract] [Full Text] [PDF]

				G. Ha Van, H. Siney, A. Hartmann-Heurtier, S. Jacqueminet, F. Greau, and A. Grimaldi Nonremovable, Windowed, Fiberglass Cast Boot in the Treatment of Diabetic Plantar Ulcers: Efficacy, safety, and compliance Diabetes Care, October 1, 2003; 26(10): 2848 - 2852. [Abstract] [Full Text] [PDF]

				C. Caravaggi, R. De Giglio, C. Pritelli, M. Sommaria, S. Dalla Noce, E. Faglia, M. Mantero, G. Clerici, P. Fratino, L. Dalla Paola, et al. HYAFF 11-Based Autologous Dermal and Epidermal Grafts in the Treatment of Noninfected Diabetic Plantar and Dorsal Foot Ulcers: A prospective, multicenter, controlled, randomized clinical trial Diabetes Care, October 1, 2003; 26(10): 2853 - 2859. [Abstract] [Full Text] [PDF]

				D. G. Armstrong, L. A. Lavery, H. R. Kimbriel, B. P. Nixon, and A. J.M. Boulton Activity Patterns of Patients With Diabetic Foot Ulceration: Patients with active ulceration may not adhere to a standard pressure off-loading regimen Diabetes Care, September 1, 2003; 26(9): 2595 - 2597. [Abstract] [Full Text] [PDF]

				A. J. M. Boulton and D. G. Armstrong Trials in Neuropathic Diabetic Foot Ulceration: Time for a paradigm shift? Diabetes Care, September 1, 2003; 26(9): 2689 - 2690. [Full Text] [PDF]

				M. J. Mueller, D. R Sinacore, M. K. Hastings, M. J. Strube, and J. E Johnson Effect of Achilles Tendon Lengthening on Neuropathic Plantar Ulcers*: A Randomized Clinical Trial J. Bone Joint Surg. Am., August 1, 2003; 85(8): 1436 - 1445. [Abstract] [Full Text] [PDF]

				L. A. Lavery, D. G. Armstrong, R. P. Wunderlich, J. Tredwell, and A. J.M. Boulton Predictive Value of Foot Pressure Assessment as Part of a Population-Based Diabetes Disease Management Program Diabetes Care, April 1, 2003; 26(4): 1069 - 1073. [Abstract] [Full Text] [PDF]

				J. R. Goldsmith, R. H. Lidtke, and S. Shott The Effects of Range-of-Motion Therapy on the Plantar Pressures of Patients with Diabetes Mellitus J Am Podiatr Med Assoc, October 1, 2002; 92(9): 483 - 490. [Abstract] [Full Text] [PDF]

				D. D. Robertson, M. J. Mueller, K. E. Smith, P. K. Commean, T. Pilgram, and J. E. Johnson Structural Changes in the Forefoot of Individuals with Diabetes and a Prior Plantar Ulcer J. Bone Joint Surg. Am., August 12, 2002; 84(8): 1395 - 1404. [Abstract] [Full Text] [PDF]

				D. G. Armstrong, L. A. Lavery, J. R. Vazquez, B. P. Nixon, and A. J. M. Boulton How and Why to Surgically Debride Neuropathic Diabetic Foot Wounds J Am Podiatr Med Assoc, July 1, 2002; 92(7): 402 - 404. [Abstract] [Full Text] [PDF]