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New Trends in the Orthopaedic Management of Diabetic Foot
±Û¾´ÀÌ : °ü¸®ÀÚ ³¯Â¥ : 2018-09-21 (±Ý) 12:07 Á¶È¸ : 2411
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New Trends in the Orthopaedic Management of Diabetic Foot

EFORT Open Rev. 2018 May 21;3(5):269-277

 

1. Novel preventive approaches to diabetic foot ulcers (DFUs)

1.     ¾ö°ÝÇÑ Ç÷´çÁ¶ÀýÀÌ °¡Àå Áß¿äÇϸç, ´ç´¢ ÇÕº´ÁõÀ» ¿¹¹æÇÏ´Â °ÍÀ¸·Î À¯ÀÏÇÏ°Ô Áõ¸íµÈ ¹æ¹ýÀÓ.

2.     Higher resolution infrared thermal imaging: ±Ë¾ç ¹ß»ý ¹× Àç¹ßÀ» ¿¹¹æÇϴµ¥ À¯¿ëÇÔ.

3.     Hyperspectral imaging: Á¶Á÷ ³» oxygen saturation ÃøÁ¤ÇÏ´Â »õ·Î¿î ±â¼ú. ´ç´¢¹ß¿¡¼­ microvascular diseases Á¶±â Áø´Ü¿¡ »ç¿ëµÊ. 

4.     Skin perfusion pressure-testing system: microvascular disease¸¦ ¹ß°ßÇÏ°í ´ç´¢¹ß ±Ë¾çÀÇ Ä¡À¯ °¡´É¼ºÀ» ¿¹ÃøÇϴµ¥ »ç¿ëµÇ´Â »õ·Î¿î portable device.

5.     Hyperspectral imaging + Skin perfusion pressure: ´ç´¢È¯ÀÚ¿¡¼­ peripheral arterial disease Á¶±â¹ß°ß¿¡ À¯¿ëÇÔ.

 

2. New diagnostic technologies and strategies for diabetic foot infections (DFIs)

: ÀÓ»óÀû °Ë»ç¿Í °íÀüÀû ¿µ»óÇÐÀû °Ë»ç (ex) x-ray, ÃÊÀ½ÆÄ, CT)´Â ´ç´¢¹ß °¨¿° Áø´Ü¿¡ À¯¿ëÇÏÁö ¾ÊÀ½.

1.     MRI: ´ç´¢¹ß °¨¿° Áø´Ü¿¡ °¡Àå À¯¿ëÇÑ °Ë»ç. ÇÏÁö¸¸, osteomyelitis¿Í Charcot neuroarthropathy ±¸ºÐ¿¡´Â Á¦ÇÑÁ¡ÀÌ ÀÖÀ½.

2.     New functional MRI modalities: Dixon imaging, Diffusion-weighted imaging, Dynamic contrast-enhanced MRI: osteomyelitis¿Í Charcot neuroarthropathy ±¸ºÐ¿¡ Èï¹Ì·Ó°Ô ¼Ò°³µÇ°í ÀÖÀ¸³ª ´ç´¢¹ß Æò°¡¸¦ À§ÇØ routineÀ¸·Î »ç¿ëµÇÁö´Â ¾ÊÀ½.

3.     FDG-PET & Radiolabelled WBC scintigraphy: ÃÖ±Ù ¸ÞŸ ¿¬±¸ °á°ú ´ç´¢¹ß¿¡¼­ osteomyelitis ¹ß°ß¿¡ high specificity¸¦ Á¦°øÇÏ´Â °ÍÀ¸·Î Áõ¸íµÊ.

 

3. Current non-surgical treatment options for DFUs

: ´ç´¢¹ß ±Ë¾ç Ä¡·á ¿øÄ¢

1)     °¨¿° Á¶Àý

2)     öÀúÇÑ off-loading

3)     Debridement¿Í Wound healing, ±×¿Í ´õºÒ¾î Ç÷´çÁ¶Àý, ½ÉÇ÷°ü°è À§Ç輺, revascularization ¹× ¼ö¼úÀû óġ °¡´É¼º µî ´Ù¹æ¸éÀûÀ¸·ÎÀÇ Á¢±Ù

Off-loading treatment

: ´ç´¢¹ß ±Ë¾çÀÇ primary treatment´Â Restriction of weight-bearingÀÓ. ÀÌ´Â »óó Ä¡À¯¸¦ È£Àü½ÃÅ°°í ±Ë¾ç Àç¹ßÀ» ¸·¾Æ ±Ã±ØÀûÀ¸·Î amputationÀ» ¹æÁöÇÔ.

Ex) total contact casts, removable cast walkers, therapeutic footwear, foot orthoses, custom shoes, custom braces, padding, strapping therapy

1.     Total contact cast: RCT ¿¬±¸ °á°ú total contact cast°¡ removable devices¿Í ºñ±³ÇÏ¿© »óó Ä¡À¯ ¼Óµµ¿Í Ä¡À¯µÉ ¶§±îÁöÀÇ ½Ã°£ ¸ðµÎ ´õ ³ªÀº °ÍÀ¸·Î º¸°íµÊ.

2.     Variety of therapeutic footwear: È¿°úÀûÀÎ pressure off-loadingÀ» ÇÏ¿© ´ç´¢¹ß ±Ë¾ç ¹ß»ý°ú Àç¹ßÀ» ¸·±â À§ÇØ ÃÖ±Ù ´Ù¾çÇÑ ¹æ¹ýÀ¸·Î Àû¿ëµÇ°í ÀÖÀ½. ¾ÆÁ÷ ±× È¿Ç輺°ú ½ÇÇà°¡´É¼º¿¡ °üÇÑ ÀÓ»óÀû ¿¬±¸°¡ °ÅÀÇ ¾ø´Â »óÅÂÀÓ.

New debridement methods and advanced wound-healing strategies

<Debridement>

1.     Scalpel & Scissor: ´ç´¢¹ß ±Ë¾ç¿¡ ÀÖ¾î ±âÁØÀÌ µÇ´Â Ä¡·áÀÓ.

2.     Larval therapy: ¸¸¼ºÀÇ, Ä¡À¯µÇÁö ¾Ê´Â ´ç´¢¹ß »óó¿¡ »ç¿ëµÊ. °­·ÂÇÑ ÀÓ»óÀû ±Ù°Å´Â ¾øÁö¸¸ ¾ÈÀüÇÏ°í È¿°úÀûÀÎ biosurgical debridement·Î ¾Ë·ÁÁ® ÀÖÀ½.

3.     Varsajet Hydrosurgery System (Smith and Nephew, London, UK): »ý¸®½Ä¿°¼ö¸¦ ³ôÀº ¾Ð·ÂÀÇ jet-streamÀ¸·Î »Õ¾î³¿À¸·Î½á »óó¸¦ debride ÇÏ´Â »õ·Î¿î Á¦Ç°. prospective randomized controlled clinical study°á°ú debridement¿¡ ºü¸£°í È¿°úÀûÀÎ °ÍÀ¸·Î º¸°íµÊ.

4.     Clostridial collagenase: novel enzymatic debridement method.

< New generation of modern wound dressing>

1.     Extracellular matrix (Biological dressing) (ex)collagen, hyaluronic acid, chitosan, elastin, fibrin): ¾î¶² µå·¹½ÌÀÌ ´ç´¢ ¹ß ±Ë¾ç¿¡¼­ °¡Àå ³ªÀºÁö¿¡ ´ëÇÑ ¿¬±¸´Â ¾øÀ¸¸ç RCT °á°ú ƯÁ¤ µå·¹½ÌÀÌ ´Ù¸¥ µå·¹½Ìº¸´Ù ´õ ³´´Ù´Â °á·ÐÀº ¾øÀ½.

2.     Advanced biological therapies (ex)platelet-rich plasma, bioengineered cell-based therapies, recombinant growth factors (r-GF)): Àß ³´Áö ¾Ê´Â ¹ß ±Ë¾ç¿¡ »ç¿ëµÊ.

3.     ÃÖ±Ù Cell based therapies (Alloegeneic bilayered human skin equivalent & dermal skin substitute)¿Í recombinant platelet-derived GF (PDGF)°¡ biological therapyÀÇ ±âÁØÀ¸·Î ¿©°ÜÁö°í ÀÖÀ½. PDGF´Â ´ç´¢¹ß ±Ë¾ç Ä¡·áÁ¦·Î °¡Àå Æø³Ð°Ô »ç¿ëµÇ°í ÀÖÀ¸¸ç À¯ÀÏÇÏ°Ô FDA½ÂÀÎÀ» ¹ÞÀº Á¦Ç°ÀÓ.

4.     Intralesional injection of recombinant human epidermal growth factor

5.     Allogeneic bilayered human skin equivalent (Apligraf¢â) & dermal skin substitute (Dermagraft¢â): human fibroblast¿Í extracellular matrix°¡ Æ÷ÇԵǾî ÀÖÀ½.

Hyperbaric oxygen therapy (HBOT)

: Oxygen free radical°ú leukocyte È°¼ºÀ» Áõ°¡½ÃÄÑ bactericidal effect¸¦ À¯¹ßÇÔ.

Negative pressure wound therapy (NPWT)

: ºÎÁ¾À» °¨¼Ò½ÃÅ°°í exudate¸¦ Á¦°ÅÇÏ°í, perfusion, cell proliferation, granulation tissue¸¦ Áõ°¡½ÃÅ´À¸·Î½á »óó Ä¡À¯¸¦ È£Àü½ÃÅ´.

 

4. Charcot foot

Current concepts of diagnosis and treatment of Charcot foot

: Charcot neuroarthropathy (CN) ¹ßº´ÀÇ ÀÓ»óÀû Áõ»óÀº erythema°¡ µ¿¹ÝµÈ warm, swollen foot and ankle. ÀÌ·± ±Þ¼º±â CNÀ» ºñ½ÁÇÑ ÀÓ»óÀû Áõ»óÀ» °¡Áø osteomyelitis, cellulitis, deep-vein thrombosis¿Í ±¸ºÐÇÏ´Â °ÍÀº ¾î·Á¿ò.

1.     MRI: CNÀÇ Á¶±â ¹ß°ß¿¡ °¡Àå sensitiveÇÑ ¿µ»óÇÐÀû °Ë»ç.

2.     Tc-MDP: abnormal woven boneÀ» ½Äº°Çϴµ¥ ³ôÀº Á¤È®µµ¸¦ °¡Áö°í ÀÖÁö¸¸, ³ôÀº bone turnover¸¦ ¾ß±âÇÏ´Â ÀÓ»óÀû »óÅÂ, ¿¹¸¦ µé¸é °¨¿°, ¼ö¼ú, ¿Ü»ó°ú °°Àº °æ¿ì¿¡´Â specificity rate¸¦ ¶³¾î¶ß¸².

3.     Labeled white cell scans (In-WBC): osteomyelitis¸¦ °¨ÁöÇÏ°í °æ°ú °üÂûÇϴµ¥ À¯¿ëÇÔ.

4.     In-WBC + Tc-MDP: Charcot foot¿¡¼­ ±Ë¾ç°ú °ü·ÃµÈ ¹ß º¯ÇüÀ» Áø´ÜÇϴµ¥ specificity¿Í sensitivity¸¦ Áõ°¡½ÃÅ´.

Surgical treatment

: Charcot footÀÇ primary treatment´Â ºñ¼ö¼úÀû Ä¡·á·Î ³Î¸® ¾Ë·ÁÁ® ÀÖÀ¸¸ç total contact casting°ú ´Ù¾çÇÑ bracing ¹× therapeutic foot wear¿Í °°Àº off-loading ¹æ¹ýÀ¸·Î ½ÃÇàµÇ°í ÀÖÀ½.

: ±×·³¿¡µµ ºÒ±¸ÇÏ°í ¹ßÀÇ instability¸¦ ¾ß±âÇÏ´Â °æ¿ì ±Ã±ØÀûÀ¸·Î ¼ö¼úÀ» ½ÃÇàÇÏ´Â °æ¿ì°¡ ÀÖÀ½.

: Superconstruct techniques

-       Fusion beyond the injury zone

-       Bone resection to permit reduction with limited tension on the soft-tissue envelope

-       Use of the strongest implants and device positioning that maximizes the mechanical function

: CN¿¡¼­ ¼ö¼úÀû óġ¿¡ ´ëÇÑ Çʿ伺¿¡ °üÇؼ­´Â ¾ÆÁ÷ ¸¹ÀÌ ¾Ë·ÁÁöÁö ¾Ê¾ÒÀ¸¸ç ÀûÀýÇÑ ¼ö¼ú½Ã±â ¹× ¹æ¹ý·Ð¿¡ °üÇؼ­µµ ¿©ÀüÈ÷ ÀÇ°ß ÀÏÄ¡°¡ ¾ø´Â »óȲÀÓ.

Medical treatment

1.     Bisphosphonate in the treatment of acute CN: ¾ÆÁ÷ ÁÖ¸ñÇÒ ¸¸ÇÑ evidence´Â ¾øÀ½.

2.     Receptor activator of nuclear factor-¥ê¥â ligand (RANKL): acute CN¿¡¼­ osteoclastic activity¸¦ Áõ°¡½ÃÅ´.

3.     TNF-¥á: RANKL¿Í ¿¬°üµÇ¾î osteoclastic resorptionÀ» Á¶Àý.


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