鞋具對糖尿病足潰瘍高?；颊哳A(yù)防的有效性：國際糖尿病足工作組2023年糖尿病足診療指南足潰瘍預(yù)防部分解讀

工作組2023年糖尿病足診療指南足潰瘍預(yù)防部分解讀際糖尿病足工作組的首要事項。該文對國際糖尿病足工作組2023年糖尿病足診鞋具對潰瘍發(fā)生率/復(fù)發(fā)率、足底壓力的影響，同時關(guān)注死亡率、不良事件、依鞋用率和高復(fù)發(fā)率等特征[1]。國際糖尿病足工作組(InternationalWorkingGroupontheDiabeticFoot,IWGDF)始終把足潰瘍的預(yù)防視為首要事項。足潰瘍的危險因素包括保護性感覺喪失(lossofprotectivese足畸形、外周動脈疾病(peripheralS或PAD加以下任何1項：足潰瘍史、下肢截肢史、晚期腎臟疾病。病變、預(yù)防性手術(shù)、心理指導(dǎo)等，效果并不確切。本文對2023年糖尿病足診療分組方法進行分類總結(jié)，重點關(guān)注不同鞋具對潰索到3項隨機對照試驗(randomizedcontrolledtrial,RCT)[2-4]和3項隊列研究[5-7]。3項RCT符合Meta分析納入標(biāo)準(zhǔn)，應(yīng)用Meta分析評估3鞋具有保護性作用，但差異無統(tǒng)計學(xué)意義且異質(zhì)性高。3項隊列研究中，1項未發(fā)現(xiàn)治療性鞋具與普通鞋具的差異，2項證實足底壓力方面，1項隊列研究[7]和18項非RCT[8-26]均提示，與普通準(zhǔn)鞋墊指已臨床應(yīng)用于相關(guān)類型潰瘍預(yù)防的鞋墊。該條目共檢索到5項RCT[27-31]和20項非RCT[32-51]。結(jié)果顯示，與標(biāo)準(zhǔn)鞋墊相比，降低剪切力的足底壓力方面，目前有2項RCT和20項非RCT報告了足底壓力。由于鞋墊元素及其效果存在很大差異(例如，同一元素可能效果[44]),無相關(guān)證據(jù)陳述。至于其他結(jié)果，不良事件(1項RCT)、健康相關(guān)生命質(zhì)量(HRQoL,1項RCT)和依從性(2項RCT)方面差異沒有統(tǒng)計學(xué)意義。指制式統(tǒng)一的治療性鞋具。該條目在預(yù)防潰瘍方面共檢索到4項RCT[52-55]和3項RCT[56-58],對其中2項符合Meta分析納入標(biāo)準(zhǔn)的RCT進行Meta發(fā)現(xiàn)，潰瘍復(fù)發(fā)的相對危險度為0.62,與標(biāo)準(zhǔn)組相比，壓力優(yōu)化組有保護性趨勢，但差異無統(tǒng)計學(xué)意義且異質(zhì)性高。其他2項RCT未發(fā)現(xiàn)二者潰瘍發(fā)生率的差異。關(guān)注足底壓力的3項RCT和3項非RCT均顯示，與標(biāo)準(zhǔn)治療鞋相比，壓力優(yōu)間加厚，兩頭微翹起)的治療鞋。試驗組根據(jù)3D掃描患者足部尺寸、模型和體尿病患者中，與標(biāo)準(zhǔn)治療鞋相比，基于足部3D掃描選擇的治療性鞋具對足潰瘍硅趾矯形器是指應(yīng)用硅膠材料定制的分趾矯形器。1項RCT[60]比較了硅趾矯形器與其他矯形器在低中潰瘍風(fēng)險(IWGDF風(fēng)險1或2)人群中的預(yù)防效果，人群(IWGDF風(fēng)險1)步態(tài)康復(fù)的效果。結(jié)果發(fā)現(xiàn)，與步態(tài)康復(fù)期間不穿震動鞋墊的患者相比，在8周步態(tài)康復(fù)計劃后，震動鞋墊2項RCT[28,52]和1項隊列研究[62]比較了治療性鞋具依從性好的參與者與依從性差的參與者之間的差異，3項研2項非RCT描述了使用專為潰瘍高風(fēng)險人群(IWGDF風(fēng)險3)設(shè)計的室內(nèi)治療鞋的對患者依從性的影響[62-63]。結(jié)果顯示，基線時依從性差的參與者在使用專用鞋具1個月和12個月后依從性顯著提高(基線時中位數(shù)為65%;1個月后為77%;12個月后為87%),基線時依從性好的參與者無明顯變化[62]。該隊列整體1年內(nèi)潰瘍復(fù)發(fā)率為26%。與常規(guī)定制性鞋具相比，專用治療性鞋具對關(guān)文獻中對照研究18項，非對照研究超過40項，從一定程度上證實了鞋具對降難以推廣。隨著定制化鞋具的有效性證據(jù)的不斷積累和方法的不斷成熟[4,64],有效性的關(guān)鍵環(huán)節(jié)和重要挑戰(zhàn)[28,52,62],進一步的研究還在進行中。ecurrence[J].NEnglJMed,2017,epreventionofdiabeticfootulcers[J].DiabetesCare,1995,18trolledtrial[J].JAMA,2002,287(19):2552-2558.DOI:10.1001/jama.[4]RizzoL,TedeschiA,FallaniE,eropathiculcersinhigh-riskdiabeticfootpatients[J].IntJLowExtremWounds,2012,11(1):59-64.DOI:10.1177/1534734612438729.[5]ReikeH,BruningA,Rischdedorthoticdevice[J].Diabetes[6]BuschK,ChantelauE.Effectivenessofanewbrandofstock'diabetic'shoestoprotectagainstectivecohortstudy[J].DiabetMed,2[7]ViswanathanV,Madhavaofdifferenttypesoffootwearinsolesforthediabeticneuropatoot:afollow-upstudy[J].DiabetesCare,2004abetMed,1990,7(4):355-359.DOI:10.1111/j.1464-5491.1990.tb01[9]BaumannR.Efficacyofindustriallyprodu[10]BorssénB,BergenheimT,Lithnerdemiologicalandprospective9-225.DOI:10.1046/j.1365-2796.1996[11]StriesowF.[Specialmanufacturedshoesentulcerindiabeticfootsyndrome][J].MedKlin(Mu[12]FriggA,PagenstertG,Sch?ferDonofdiabeticfootulcersaftertotalcontactcasting[J].FootAnkleInt,2007,28(1):64-69.DOI:10.3113/FAI.20nbyanewmethodofcustom-madeshoesinhreshoesfordiabetics.009,38(12):1209-1214.DOI:10.1007/[15]FernandezML,LozanoRM,Diafinthediabeticfootusingforefootofflpressuresinneuropathicfeet[J].D[18]KavrosSJ,VanStraatenntarpressurereductionofoff-the-shelfrockerbottomprovisionalfootwear[J].ClinBiomech(Bristol,Avon),2011,26(7):778-782.DOI:[19]ChapmanJD,PreeceS,BraunsteinB,edesignfeaturesonforefootplantarpressuresinpeoplewithandwithoutdiabetes[J].ClinBiomech(Bristol,Avon),2013,28(6):679-685.DOI:10.1016/j.clinbiomech.2013.05.005.BronzeAward.Comparisonofstrategiesforreducingpressureatthesiteofneuropathiculcers[J].JAmPodiatrMedAssoc,1997,87(10):[21]RaspovicA,LandorfKB,GazarekJ,etal.Reductionofpeakplantarpressureinpeoplewithdiabete2012,5(1):25.DOI:10.1186/1757-1146-5-25.[22]LinTL,SheenHM,ChungCT,etal.peoplewithdiabeticperipheralneuropathy[J].JFootAnkleRes,2013,6(1):29.DOI:10.1186/1757-1146-6-29.reintheneuropathicfoot.Acomparisonof[24]ZwaferinkJ,CustersW,PaardekooperI,etal.Effectofacarbooffootulceration[J].GaitPosture,2021,86:341-345.DOI:10.101[25]López-MoralM,Momportanceoffootwearoutsoleri[26]KarimiMT.Theevaluationoffootrockersonthekinematicparametersofindividualswithdiabetes[J].FootAnkleSpec,2018,11(4):lestopreventfootulcerationinhigh-riskdvSkinWoundCare,2012,25[28]López-MoralM,Lázaro-Martinezthepreventionofrecurrenceinpatientswithdiabetesmelliiabeticpolineuropathy:arandomizedclinicaltrial[J].[29]ColagiuriS,MarsdenLL,NaiduV,etal[30]PatonJS,StenhouseEA,BruceG,etal.Acompaiabeticfootulceration:aparticipant-blinded 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