Healing Times of Pedal Ulcers in Diabetic Immunosuppressed Patients After Transplantation.

Healing Times of Pedal Ulcers in Diabetic Immunosuppressed Patients After Transplantation Sinacore DR (Program in Physical Therapy and Department of Medicine, Washington University School of Medicine, St Louis, Mo), Arch Phys Med Rehabil. 1999;80:935-940

The purpose of this study was to compare healing times following total contact casting (TCC) of subjects with diabetes who were on lifelong immunosuppressive medications with subjects who had not had transplants.

Nine outpatients (7 men) who had transplants were compared with 14 outpatients (control subjects) who were similar but had not received a transplant and were not immunosuppressed. The control group tended to be older, with a higher percentage of members diagnosed with type II diabetes mellitus of a shorter duration and with statistically significant different location of ulceration. The patients were recruited over a 6.5-year period. Seven subjects in the experimental group received kidney transplants, one subject received a liver transplant, and one subject received a pancreas transplant. The most common immunosuppressive agents were cyclosporine, prednisone, and azathioprine, usually used in combination. Both groups included a person who had received a transmetatarsal amputation. The control group included a subject with a below-knee amputation, and the experimental group included a subject with a fifth ray amputation.

Wound size was determined by tracing the wound boundary on sterile acetate using an optical digitizer and then calculating the mean of 3 tracings. The depth was calculated at the deepest point with a modified sliding ruler. Neuropathy was determined at specified plantar sites by using a 5.07 (10 g) Semmes-Weinstein monofilament, by the presence of intrinsic muscular weakness, or by the absence of a plantar reflex. One of 2 therapists with extensive experience used the same procedures and casting materials and changed casts every 1 or 2 weeks until the wound healed. During standing and walking with an assistive device, partial weight bearing was permitted and reinforced with no attempt to measure the actual amount of weight bearing. Healing time was defined as the time when there was no drainage or sinus tracts and epithelialization (skin closure) occurred. Because the cast did not allow daily assessment, healing may have occurred any day within a week. Modified or prescribed footwear was utilized by all subjects within the experimental group. Follow-up was conducted 1 month after healing.

The statistics used included mean, standard deviation, and 95% confidence interval for mean healing time. A one-way ANOVA was used for continuous variables and a [chi square] test for categorical variables. An ANCOVA was performed to control for the effect of variables that were different between the 2 groups.

All ulcers in both groups healed, but the time it took for healing differed between the 2 groups. The pedal ulcers of those in the experimental group healed an average of 111 [+ or -] 25 days compared with an average of 47 [+ or -] 18 days in those in the control group. Neither group had members who required an amputation during the follow-up period. Axillary crutches and a walker were required by 2 patients in the experimental group. Five patients had a recurrence of ulceration: one subject with a transmetatarsal amputation in the experimental group, and 4 of the 14 control subjects. All of the ulcers healed.

The researchers concluded that TCC is a highly effective and rapid intervention for neuropathic pedal ulcers in patients who were immunosuppressed and had received a transplant. The researchers also stated that the process of ulcer healing took several weeks longer than it would take for patients whose immune systems were not compromised.

Barbara Hanley, PT Helen Hayes Hospital West Haverstraw, NY