Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes

people who did not achieve healing at the end of the study and 13 people had anosteomyelitis during the follow-up. Secondary osteomyelitis developed in 3 patientsin the cast boot group (7%) and 13 patients in the off-loading shoe group (25%)(p=0.026).However, not all studies have had positive outcomes. Reiber et al (2002a) studied 400people (mean age 62 years) who were randomly assigned to receive 3 pairs oftherapeutic shoes with cork inserts, or 3 pairs of therapeutic shoes with prefabricatedinserts, or assigned to wear their usual footwear for 2 years. At baseline, 58% ofpeople were insensitive to the 10g monofilament and 32% had moderate footdeformity. A total of 95 reulcerations occurred during the 2-year follow-up. Thecumulative reulceration incidence across the 3 groups was similar: 15% in the corkinsertgroup, 14% in the prefabricated-insert group, and 17% in the control group.People assigned to therapeutic shoes did not have a significantly lower risk ofreulceration compared with controls - RR was 0.88 (95% CI 0.51-1.52) for the corkinsertgroup, and 0.85 (95% CI 0.48-1.48) for the prefabricated-insert group.A cohort of 352 people with Type 2 diabetes were followed over 12 months to assessthe impact of footwear on the development of foot wounds (Litzelman et al, 1997b).At examination at 12 months 63 feet (53 people) had either a blister or wound.Contrary to expectation, a recommendation to wear special footwear was associatedwith increased risk of foot wounds at follow up (OR 2.19, CI 1.07-4.49; p=0.03).However the study group was not provided with therapeutic footwear or better accessto therapeutic footwear and in fact only one person actually wore the special footwear.Edmonds et al (1986) reported the 3-year outcomes of a specialised foot clinic forpeople with diabetes and foot ulcers. 239 people with diabetes and foot ulcers weredivided into two groups: 148 with palpable pulses in the neuropathic group and 91without foot pulses in the ischaemic group. After initial healing, 121 people in theneuropathic group were observed further, 22 of the 86 people (26%) wearing speciallyfitted shoes developed ulceration compared with 29 of the 35 people (83%) wearingtheir own shoes (Edmonds et al, 1986).Therapeutic footwear combined with podiatry care reduces the risk ofamputation in high risk individualsProtective footwear was offered to a group of high risk people with neuropathy,previous ulceration, vascular insufficiency (ABI ≤0.75) and/or foot deformity, in aRCT of a diabetic foot screening and protection programme (McCabe et al, 1998). Atotal of 2,001 people with diabetes were included in this study and were randomlyallocated to the index group (n=1,001) or the control group (n=1,000). 128 peoplewith a high risk of ulceration in the index group were recruited to a protectionprogramme which provided podiatry sevices and protective footwear. At 2-yearfollow-up, there were 24 ulcers in the index group compared with 35 ulcers in thecontrol group. Moreover, less ulcers progressed to amputation in the index group (7, 1major and 6 minor) compared with 23 amputations in the control gropu (12 major and11 minor). The difference in the total number of amputations between the two groupswas significant (p