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World J Orthop. Feb 18, 2021; 12(2): 61-68
Published online Feb 18, 2021. doi: 10.5312/wjo.v12.i2.61
Diabetic foot: Which one comes first, the ulcer or the contracture?
Raden Andri Primadhi, Herry Herman
Raden Andri Primadhi, Herry Herman, Department of Orthopaedics and Traumatology, Universitas Padjadjaran Medical School, Hasan Sadikin Hospital, Bandung 40161, Indonesia
Author contributions: Primadhi RA performed the majority working of the writing and figure preparation; Herman H provided input into the paper writing.
Conflict-of-interest statement: The authors have nothing to disclose.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Raden Andri Primadhi, MD, Assistant Professor, Surgeon, Department of Orthopaedics and Traumatology, Universitas Padjadjaran Medical School, Hasan Sadikin Hospital, Jalan Pasteur 38, Bandung 40161, Indonesia. randri@unpad.ac.id
Received: November 19, 2020
Peer-review started: November 19, 2020
First decision: December 21, 2020
Revised: December 25, 2020
Accepted: January 22, 2021
Article in press: January 22, 2021
Published online: February 18, 2021
Abstract

Diabetic foot is among the most common complications of patients with diabetes. One of the known causes of foot ulceration is ankle equinus, which increases the pressure on the plantar surface during ambulation. Conversely, equinus contracture can be caused by a complicated wound, and it may be due to prolonged immobilization. In this paper, we reviewed the pathogenesis of both conditions and their clinical considerations. Poor glycemic control in patients with diabetes may result in angiopathy and neuropathy as an underlying condition. An ulcer can be precipitated by an injury, improper foot care, or increased biomechanical loading as seen in elevated plantar pressure following equinus contracture. Equinus contracture may be a direct effect of hyperglycemia or can arise in combination with another pathway, for example, involving the activation of transforming growth factor β. Static positioning resulting from any prior foot wound may develop fibrotic changes leading to contracture. Wound healing promoting factors can also result in overhealing outcomes such as hypertrophic scarring and fibrosis. The body’s repair mechanism during the healing cascade activates repair cells and myofibroblasts, which also serve as the main producers and organizers of the extracellular matrix. Considering this intricate pathogenesis, appropriate interventions are essential for breaking the vicious cycle that may disturb wound healing.

Keywords: Diabetes, Ulcer, Contracture, Vicious cycle, Pathogenesis, Intervention

Core Tip: There is a complex pathogenesis of diabetic foot ulcers, including many variables that are involved in a vicious cycle. This is the first review to analyze the relationship between contracture and ulcer formation, with the aim of formulating a more detailed pathogenesis and timeline for better treatment strategies.