Podiatry
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Item Biofilm in Diabetic Foot Ulcers: A Systematic Narrative Review(Wiley, 2025-12-03) Theodorakopoulos, George; Armstrong, David G.Biofilms are a key driver of chronicity and treatment failure in diabetic foot ulcers (DFUs), yet clinical evidence quantifying their impact and management remains fragmented. This systematic narrative review synthesised recent evidence (2015–2025) on the prevalence, diagnostics, and management of biofilm in DFUs. A Systematic Review of the Literature (SRL) was conducted following PRISMA 2020 guidelines across PubMed/MEDLINE, Scopus, Cochrane Library and ScienceDirect. Eligible studies included adults with DFUs reporting biofilm/bioburden metrics or interventions aimed at biofilm disruption. Risk of bias was assessed using RoB 2 for randomised trials and ROBINS-I for non-randomised studies. Data were narratively synthesised by evidence tier (Tier 1 = clinical; Tier 2 = preclinical/mechanistic). Of 600 records screened, 25 studies met inclusion criteria (Tier 1 n = 9; Tier 2 n = 5; reviews n = 11). Over half of bacterial isolates in DFUs were biofilm producers, with multidrug resistance exceeding 90% in several cohorts. Fungi were detected in 31% of ulcers by qPCR but only 9% by culture. Tier 1 clinical evidence supports standard care components—debridement, antiseptics, and negative-pressure wound therapy—for improved healing, though direct antibiofilm outcomes remain limited. Emerging strategies (enzymatic agents, peptides, cold plasma, smart dressings) show promise in vitro but lack clinical translation. Evidence for direct antibiofilm efficacy in DFUs remains scarce. Current data justify maintaining guideline-based care while prioritising trials that integrate validated biofilm endpoints, standardised microbiological methods, and antifungal components. Distinguishing established from experimental approaches is essential to advancing safe, evidence-based biofilm management in DFUs.Item Collagen–ORC Versus Standard Treatment in Diabetic Foot Ulcers: A Systematic Review and Meta‐Analysis of Randomised Trials(Wiley, 2025-11-17) Theodorakopoulos, George; Armstrong, David G.Diabetic foot ulcers (DFUs) are a major cause of infection, hospitalisation, and amputation. Collagen-based dressings—especially collagen combined with oxidised regenerated cellulose (ORC)—are proposed to improve healing by modulating matrix metalloproteinases (MMPs), stabilising the extracellular matrix (ECM), and tempering inflammation; some formulations also include antimicrobial or bioactive adjuncts. We conducted a systematic review of randomised controlled trials (RCTs) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Adults with DFUs were eligible. Interventions included collagen-alone or collagen-combination dressings (e.g., collagen–oxidised regenerated cellulose [collagen–ORC]/silver, collagen–chitosan) versus standard of care (SOC) or alternative dressings. To ensure comparable outcomes, the quantitative synthesis was pre-specified and restricted to complete wound closure (yes/no, intention-to-treat [ITT]) from collagen-combination RCTs with aligned constructs; other outcomes were synthesised narratively. Meta-analyses were performed in Microsoft Excel using Mantel–Haenszel methods for risk ratios (RR) with a fixed-effect primary model and DerSimonian–Laird random-effects sensitivity analysis; heterogeneity was summarised with Cochran's Q, between-study variance (τ2), and Higgins' I2 statistic (I2), and a 95% prediction interval was reported for random-effects. (Protocol not registered). Six studies (five randomized controlled trials and one single-blinded non-randomized comparative study; total n = 314) met inclusion. In a focused meta-analysis of the two collagen-combination RCTs, treatment was associated with a higher probability of complete wound closure versus control (RR 1.69, 95% confidence interval [CI] 1.05–2.72; I2 = 0%). One assessor-blinded RCT of collagen alone reported higher 12-week closure versus a placebo dressing and was not pooled due to heterogeneity. Across studies, signals also favored collagen-based care for earlier area reduction and, in one trial, fewer infection-related withdrawals; mechanistic work showed reductions in MMP-9/TIMP-2. However, most trials were small and single-centre, comparators and adjuncts varied, follow-up was short (~8 days–24 weeks, clinical endpoints typically 4–20 weeks), outcome definitions were non-standardised, and key confounders (off-loading, infection management, vascular status, glycaemic control) were inconsistently addressed. Collagen-based dressings—particularly collagen-combination formulations—appear to improve complete closure when added to the standard of care (SOC) for diabetic foot ulcers (DFUs), but the evidence is limited by study size, heterogeneity, and risk of bias. Larger, prospectively registered, multicentre RCTs with standardised outcomes and longer follow-up are needed to define clinical and cost-effectiveness and to identify which patients benefit most. Collagen–ORC dressings show promise as an adjunctive treatment for DFUs by influencing the inflammatory microenvironment and supporting tissue repair. However, the certainty of the current evidence remains limited, highlighting the need for further high-quality randomised studies. Summary In randomized trials, collagen-ORC and other collagen-combination dressings used adjunctively to standard care were associated with a higher chance of complete closure versus comparators. Individual studies also showed earlier wound-size reduction and protease-modulating effects. Certainty remains limited by small, mostly signle-center RCTs, heterogeneous comparators/endpoints, and short follow up-larger, trials are needed.Item Enablers and barriers of e-learning utilising smart technologies in type 2 diabetes care for clinicians: a systematic review(BMJ, 2025-11-16) Alanazi, Maha Mouidh; Fellas, Antoni; Bridge, Pascale; Acharya, Shamasunder; Santos, Derek; Sculley, Dean; Girones, Xavier; Coda, AndreaObjectives Continuous Glucose Monitoring (CGM) supports Type 2 Diabetes (T2D) management, but healthcare professionals (HCPs) often face challenges interpreting data. E-learning platforms can enhance knowledge, skills and confidence. This systematic review identified enablers and barriers to e-learning for CGM interpretation. Design Systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data sources PubMed, Ovid MEDLINE, Ovid Embase, Cochrane Library, Scopus, Web of Science and CINAHL were searched on 7 February 2024. Eligibility criteria for selecting studies Studies of HCPs using e-learning for T2D management were included, both comparative and non-comparative. Outcomes included enablers and barriers. Eligible designs were randomised, quasi-experimental, controlled before-and-after and observational studies. No restrictions on setting or language; conference abstracts included if full text was available Data extraction and synthesis Two reviewers independently screened and extracted data using a predefined form; disagreements were resolved by a third reviewer. Thematic analysis identified key enablers and barriers. Methodological quality was assessed using the Downs and Black checklist, and findings were synthesised narratively. Results Four studies met inclusion criteria, including 6790 participants (physicians, nurses, midwives and medical residents). E-learning improved knowledge and skills. Emami et al reported increased knowledge of T2D diagnosis and treatment (p=0.001), while Okuroğlu and Alpar found improvements in diabetes care knowledge and skills (p<0.001). Harris et al noted enhanced self-reported performance (p=0.03) and 84% satisfaction. Enablers included flexibility and accessibility, while barriers involved time constraints, resistance to change and methodological limitations (self-selection bias, lack of blinding). Study quality ranged from fair (three studies) to poor (one study). Conclusion Based on current evidence, it is unclear if e-learning can significantly enhance HCPs’ knowledge, skills and confidence in T2D management. Barriers such as time constraints and resistance to change remain, and the limited number and quality of studies restrict the generalisability of these findings. E-learning may offer potential benefits, but further robust randomised controlled trials are needed to evaluate long-term outcomes and strategies to overcome these challenges.Item Physical and mechanical therapies for lower limb problems in children with juvenile idiopathic arthritis: a systematic review with meta-analysis(Wiley, 2025-11-04) Fellas, Antoni; Hawke, Fiona; Maarj, Mohammed; Singh-Grewal, Davinder; Santos, Derek; Coda, AndreaObjective To systematically review the evidence for physical (for e.g. strengthening) and mechanical (for e.g. foot orthoses) therapies for lower limb problems in children with juvenile idiopathic arthritis (JIA). Methods Randomised clinical trials of physical and mechanical interventions for lower limb problems in children with JIA were included. The primary outcome was pain and secondary outcomes included disability, functional ability, and quality of life. Electronic databases were searched for eligible studies. Authors of included studies and researchers in the field were contacted to identify additional studies. Results Two authors independently screened 4876 titles and abstracts. Eleven randomised clinical trials were ultimately included. Four studies explored the effect of foot orthoses and seven physical therapies. Studies evaluating the effect of foot orthoses on foot and ankle pain were pooled in a meta-analysis. Results showed that foot orthoses were statistically and clinically significant in reducing both parent (−11.08 [−20.25, −1.90]) and child (−21.45 [−30.18, −12.73]) reported foot and ankle pain after 3 months compared to the control. This significant effect was sustained post 3 months. Physical therapies such as Pilates and underwater exercises were statistically and clinically significant in reducing lower limb pain after 3 months of intervention. Conclusion Foot orthoses can be prescribed to significantly reduce foot and ankle pain for children with JIA. Physical therapies appear to reduce pain during 3 months of intervention versus the control but are currently hampered by lack of blinding. Further research is also required to determine the effect of physical therapies past 3 months.Item Early Weight-bearing Following Modified Lapidus Arthrodesis: A Retrospective Review of 104 Cases & Postoperative Protocol(Elsevier, 2025-09-27) Uddin, Akram; Bramall, John W.; Leong, Keng; Klos, Kajetan; Roth, Edgar; Santos, DerekBackground Lapidus arthrodesis is indicated for the treatment of first ray dysfunction or hypermobility, hallux valgus (HV) and functional hallux limitus (FHL). Postoperative weightbearing protocols vary amongst surgeons. Purpose To report radiographic osseous healing and patient-reported outcome measures (PROMS) following a single early weightbearing protocol. Study Design Retrospective review of 104 adults (≥18 years) (104 feet) who underwent open modified Lapidus arthrodesis (without bone graft) by single compression screw and medial locking plate by two surgeons at one centre (between January 2019 to May 2023). Methods Pre- and postoperative radiographs and electronic records were reviewed for evidence of osseous healing and return to full weightbearing. Secondary measures included deformity reduction and PROMS. Results At 6-weeks follow-up 98 patients (94%) were confirmed of osseous healing and returned to full weightbearing. Six patients (6%) had delayed osseous healing at 6-weeks but showed signs of osseous healing by 3-months follow-up. Postoperative HV and intermetatarsal angle (IMA) showed significant reduction (mean difference: -12 (SD=8) and -5 (SD=4) degrees respectively; p<0.001 for both). Ten patients (10%) had postoperative complications: hardware irritation 5 (5%), sesamoiditis 2 (2%), hypertrophic scar 2 (2%) and joint stiffness 1 (1%). Eight patients (8%) required further surgery (5 required fixation removal due to hardware irritation. Three underwent either; 1st MTPJ open-mobilization, excision of scar or distal metatarsal osteotomy with tibial sesamoid planning). Manchester-Oxford Foot Questionnaire (MOXFQ) showed significant improvement across all domains (mean difference (SD): -51 (SD=22); walking/standing -49 (SD=24); pain -52 (SD=22); and social interaction -51 (SD=28); (p<0.001 for all) with clinically significant effect size (Cohen’s d: 2.37; 2.01; 2.37; and 1.84 respectively). Patient satisfaction questionnaire (PSQ-10) score was high mean of 91 (SD=8). 5 patients (5%) were lost by 6-months follow-up. Conclusion Early weightbearing achieved consistent osseous healing and high PROMS. Larger controlled studies are required to validate these results. Level of evidence Retrospective study. Level III.Item No effect of custom foot orthoses and sex on mechanical asymmetries during treadmill running(Taylor & Francis, 2025-10-07) Van Alsenoy, Ken; Santos, Derek; van der Linden, Marietta; Ryu, Joong Hyun; Al Raisi, Lubna; Girard, OlivierWe investigated the influence of custom foot orthoses and sex on mechanical asymmetries during treadmill running. Eighteen injury-free trained individuals (9 females) ran on an instrumented treadmill for six minutes at a speed 10% below their first ventilatory threshold (average: 9.9±1.3 km/h) under four footwear conditions: original shoe liner (control), two custom orthotics (one EVA, one TPU), and a hybrid (EVA heel, TPU forefoot). Vertical and antero-posterior ground reaction forces were recorded after ~5 minutes of running, encompassing 40 steps. Mechanical asymmetry was assessed using the ‘symmetry angle’ (SA) score. There were no significant main effects for condition (all P≥0.302) or sex (P≥0.137), and no significant condition × sex interactions for any variables (P≥0.063). Mean SA scores were less than 2% for contact time (0.39±0.23%), flight time (1.90±1.35%), step frequency (0.34±0.26%), peak vertical force (1.44±1.15%), and mean vertical loading rate (1.79±1.17%). Vertical and leg stiffness had mean SA scores of 3.11±1.73% and 1.86±1.00%, respectively. For braking (1.56±0.78%) and push-off (1.54±0.81%) phases and peak braking (2.94±1.61%) and push-off (2.33±1.17%) forces, mean SA scores ranged from ~1.5% to 3.0%. Overall, both male and female runners showed relatively even strides, and custom foot orthoses did not significantly alter natural stride asymmetries.Item Beyond grades: integrating communication skills into the undergraduate curriculum for podiatry students(Springer International Publishing, 2025-03-12) Coda, A.; Hawke, F.; Santos, Derek; Stevenson, E.; Girones, X.; Ruiz, X.; Escalona, C.; Sanson-Fisher, R.; Fellas, A.This commentary paper emphasises the pivotal role of effective communication in the field of podiatry and advocates for its comprehensive integration into the educational curriculum. It argues that the combination of strong academic performance and well-developed communication skills equips podiatry students to improve diagnoses and successful future treatment outcomes. These skills should be comprehensively taught and carefully assessed as part of the patient-centered care approach for podiatry students. The paper explores the multifaceted role of communication in podiatry, highlighting its importance in various aspects of the profession. These include building rapport with patients, interpreting complex medical information, and fostering a therapeutic alliance that is conducive to successful treatment outcomes. It also underscores the significance of communication in collaborating with interdisciplinary teams and advocating for patient wellbeing. Proficiency in communicating with patients can contribute to the development of a wide range of career competencies in podiatric medicine, including clinical skills, research and innovation, cultural competence, and effective teamwork, both nationally and internationally. The paper also delves into various topics such as gathering patient history, explaining diagnoses and treatment options, providing patient education, and enhancing patient outcomes through interprofessional practice. This commentary paper explores the role of communication in research participation and the teaching and assessment of communication skills through innovative methods such as role-playing, simulations, and standardized patients. In conclusion, by reiterating that the essence of podiatry extends beyond technical proficiency to include meaningful interactions between the podiatrist and the patient, which are facilitated by strong communication skills. This paper may serve as a call to action for universities nationally and internationally to place greater emphasis in integrating and thoroughly assessing communication skills in their podiatric medicine programs.Item Effects of hybrid custom foot orthoses on running economy, running mechanics and comfort: a double-blinded randomized crossover study(Elsevier, 2025-02-01) Van Alsenoy, Ken K.; van der Linden, Marietta; Santos, Derek; Girard, OlivierObjective: This study examined the effects of orthotic materials on running economy, running mechanics, and footwear comfort. Design: A double-blinded randomized crossover study design was used. Method: Eighteen athletes ran on an instrumented treadmill for six minutes at speeds corresponding to 10% below their first ventilatory threshold (average: 9.9 ± 1.3 km/h) in four footwear conditions [control (CON), Ethyl vinyl acetate (EVA), Thermoplastic Polyurethane (TPU), and a combination of EVA and TPU (HYB)]. Results: No differences were found in running economy between conditions (p=0.099). All custom foot orthoses materials reduced peak heel impact force vs CON (p<0.001). TPU reduced hysteresis at heel impact vs CON (-47.8%, p=0.016). Shorter flight time (-3.8%, p=0.016; -3.1%, p=0.021) and lower mean vertical loading rate (-4.0%, p=0.003; -7.1%, p<0.001) occurred for HYB vs TPU and CON, respectively. Higher peak vertical loading rates (+7.4%, p=0.002) and earlier impact peaks (-5.7%, p<0.001) were found for HYB vs TPU. HYB exhibited longer propulsive phase duration (+2.0%, p=0.003) but lower peak propulsive force (-3.3%, p=0.009) vs CON. Reduced ‘overall comfort’ (-26.4%, p=0.004), ‘comfort of heel cushioning’ (-43.3%, p<0.001), and ‘comfort of forefoot cushioning’ (-18.3%, p=0.048) was found for HYB vs TPU, but ‘comfort of forefoot cushioning’ (+48.0%, p=0.032) showed an increase vs EVA. Conclusions: Combining materials could enhance comfort during running causing subtle changes in running mechanics. Overall, neither EVA, TPU nor their combination significantly improved running economy compared to CON.Item Paediatric Preparedness: Document Analysis of the Challenges Experienced Using Smartwatch Technologies to Support Children Living with a Chronic Health Condition(MDPI, 2025-01-21) Butler, Sonia; Sculley, Dean; Santos, Derek; Gironès, Xavier; Singh-Grewal, Davinder; Coda, AndreaSmartwatch technology is increasingly being used to support the management of chronic health conditions. Yet, many new digital health innovations fail because the correct foundations are not well established. This exploratory study aims to uncover the challenges experienced during the setup phase of a smartwatch intervention, to support the prototype development of a digital health intervention for children. Five children with a chronic health condition were asked to wear a smartwatch for 14 days that collects health data (pain levels, medication adherence, and physical activity performance). To explore the experiences of these children, their parents and the research team, all written records were analysed using READ’s four steps of document analysis and reported using the Standards for Reporting Qualitative Research checklist. The following three themes emerged: 1.) Infrastructure limitations: inexpensive smartphones prevented connection, and outpatient clinics’ internet black spots constrained setup and training; 2.) Personal phone restrictions: limited setup, training, and engagement; 3.) Elimination of the parent’s phone: provided children with digital support (a smartphone, pre-installed apps, cellular data) to allow active participation. Overall, we identified barriers hindering the use of smartwatch technology in clinical practice. More resources are needed to ensure paediatric preparedness for digital health support.Item The effect of weight reduction on the diabetes foot: A scoping review and clinical implications(Obesity Medicine Association, 2024-12-06) Roll Ahmed, Janine E.; Veto, John; Santos, DerekBackground: This scoping review aims to explore the literature available on rapid weight reduction (either via diet/exercise or bariatric surgery) on the diabetes foot. Methods: A search strategy was developed using Population, Intervention, Comparison, Outcome (PICO). A search using all identified keywords and index terms was performed on Cumulated Index in Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), PubMed, International Clinical Trials Registry Platform (ICTRP) and Web of Science (WoS) databases as well as Proquest, and Cochrane systematic reviews. A search of grey literature was also performed on Google Scholar and Internet explorer. No restrictions were placed on the date of publication. Results: There were few studies that explored the effects of weight reduction on the diabetes foot. Only 2 articles met the scoping review's inclusion criteria. These were a case study where the intervention was bariatric surgery and a case series study where the interventions were bariatric surgery or diet and exercise. Conclusion: This scoping review has highlighted the lack of research in this area, raising opportunities for further research that focus on the effects of rapid weight reduction (either following bariatric surgery or weight reduction and diet) on the diabetes foot. Patients with diabetes mellitus should receive individualised pre and post weight reduction care to their feet, either by a podiatrist or multidisciplinary care team.