Reflecting on the Past, Present, and Future of Diabetic Foot

In the opening remarks of the Great Debates and Updates in Diabetic Foot conference in San Antonio, TX, Javier La Fontaine, DPM, MS, MEd shares four things that he feels represent the present and future of treating the diabetic foot:
·      curative surgery to prevent ulcers;
·      inframalleolar access to improve blood flow;
·      nonsurgical management of diabetic foot osteomyelitis; and
·      medical imaging to assist in diagnosis.
 
Regarding curative surgery, he points out the opportunity to correct structural foot deformity, and improve range of motion, which could in turn reduce risk of ulcer recurrence, infection, and amputation. Dr. La Fontaine stresses the importance of selecting the right patient and the right surgery for that patient.
 
The future of this concept, Dr. La Fontaine feels, lies in the role of perioperative glucose control perioperatively. He adds that HbA1c does not always provide the whole story, and that research continues to evolve that may help clinicians learn more about ideal glucose control related to diabetic foot pathology.
 
Current literature on inframalleolar access to the dysvascular foot suggests that a patent pedal arch is very important, says Dr. La Fontaine, but interesting questions continue to arise on what type of intervention will yield the best outcomes. He feels the future question to be addressed centers around the benefits of directly accessing the vessels in the foot for repair.
 
Antibiotic management of diabetic foot osteomyelitis carries clinical challenges including, but not limited to, poor delivery, kidney injury, PICC infection, and outpatient parenteral therapy cost. For best outcomes, Dr. La Fontaine reminds the audience that one needs to have a target organism to treat, stressing the importance of bone biopsy. New areas of research moving forward could include the role of polypeptides (such as pexiganan), bacteriophage therapy, antibodies, and even vaccines.
 
Dr. La Fontaine then went on to share research regarding the role of magnetic resonance imaging in evaluating osteomyelitis. He feels that future research overall is needed to best modify patient risk factors to improve surgical outcomes, learn more about using imaging to manage disease, specifically post-treatment, molecular imaging and emerging radiotracers, and more.
 
Lawrence Harkless, DPM, FACFAS, MAPWCA then reflected on the past, specifically, the events that led to the current understanding of the diabetic foot. He notes various areas of inquiry over the decades from the pathogenesis of the insensate foot and microangiopathy in the 1960s and 1970s, to the focus on the dysvascular foot, the Wagner classification, and Syndrome X in the 1980s. In the 1990s, he says thinking encompassed pathways to amputation and causation thereof, along with looking at the role of diabetic shoes. The 2000s touched on treatment and prevention and wound healing as a medical specialty. He shares that this then led to where we are today, including looking at diversity and inclusion, social determinants of health, inflammation, and pathology on a cellular level, among many other important point.
 
The Inaugural Lawrence B. Harkless Leadership in the Diabetic Foot Award was then announced with the honoree being David G. Armstrong, DPM, MD, PhD.