鞋具對(duì)糖尿病足潰瘍高?；颊哳A(yù)防的有效性：國(guó)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(xiàng)。該文對(duì)國(guó)際糖尿病足工作組2023年糖尿病足診鞋具對(duì)潰瘍發(fā)生率/復(fù)發(fā)率、足底壓力的影響，同時(shí)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(guó)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(xiàng)。足潰瘍的危險(xiǎn)因素包括保護(hù)性感覺(jué)喪失(lossofprotectivese足畸形、外周動(dòng)脈疾病(peripheralS或PAD加以下任何1項(xiàng)：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(duì)2023年糖尿病足診療分組方法進(jìn)行分類總結(jié)，重點(diǎn)關(guān)注不同鞋具對(duì)潰索到3項(xiàng)隨機(jī)對(duì)照試驗(yàn)(randomizedcontrolledtrial,RCT)[2-4]和3項(xiàng)隊(duì)列研究[5-7]。3項(xiàng)RCT符合Meta分析納入標(biāo)準(zhǔn)，應(yīng)用Meta分析評(píng)估3鞋具有保護(hù)性作用，但差異無(wú)統(tǒng)計(jì)學(xué)意義且異質(zhì)性高。3項(xiàng)隊(duì)列研究中，1項(xiàng)未發(fā)現(xiàn)治療性鞋具與普通鞋具的差異，2項(xiàng)證實(shí)足底壓力方面，1項(xiàng)隊(duì)列研究[7]和18項(xiàng)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(xiàng)RCT[27-31]和20項(xiàng)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(xiàng)RCT和20項(xiàng)非RCT報(bào)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(wú)相關(guān)證據(jù)陳述。至于其他結(jié)果，不良事件(1項(xiàng)RCT)、健康相關(guān)生命質(zhì)量(HRQoL,1項(xiàng)RCT)和依從性(2項(xiàng)RCT)方面差異沒(méi)有統(tǒng)計(jì)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(xiàng)RCT[52-55]和3項(xiàng)RCT[56-58],對(duì)其中2項(xiàng)符合Meta分析納入標(biāo)準(zhǔn)的RCT進(jìn)行Meta發(fā)現(xiàn)，潰瘍復(fù)發(fā)的相對(duì)危險(xiǎn)度為0.62,與標(biāo)準(zhǔn)組相比，壓力優(yōu)化組有保護(hù)性趨勢(shì)，但差異無(wú)統(tǒng)計(jì)學(xué)意義且異質(zhì)性高。其他2項(xiàng)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(xiàng)RCT和3項(xiàng)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(yàn)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(duì)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(xiàng)RCT[60]比較了硅趾矯形器與其他矯形器在低中潰瘍風(fēng)險(xiǎn)(IWGDF風(fēng)險(xiǎn)1或2)人群中的預(yù)防效果，人群(IWGDF風(fēng)險(xiǎn)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(dòng)鞋墊的患者相比，在8周步態(tài)康復(fù)計(jì)劃后，震動(dòng)鞋墊2項(xiàng)RCT[28,52]和1項(xiàng)隊(duì)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(xiàng)研2項(xiàng)非RCT描述了使用專為潰瘍高風(fēng)險(xiǎn)人群(IWGDF風(fēng)險(xiǎn)3)設(shè)計(jì)的室內(nèi)治療鞋的對(duì)患者依從性的影響[62-63]。結(jié)果顯示，基線時(shí)依從性差的參與者在使用專用鞋具1個(gè)月和12個(gè)月后依從性顯著提高(基線時(shí)中位數(shù)為65%;1個(gè)月后為77%;12個(gè)月后為87%),基線時(shí)依從性好的參與者無(wú)明顯變化[62]。該隊(duì)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(duì)關(guān)文獻(xiàn)中對(duì)照研究18項(xiàng)，非對(duì)照研究超過(guò)40項(xiàng)，從一定程度上證實(shí)了鞋具對(duì)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(jìn)一步的研究還在進(jìn)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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