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Wen Y, Chen L, Lan J, Li L. Efficacy of tibial cortex transverse transport in treating diabetic foot ulcer and its effect on serum omentin-1 and irisin levels. Diabetol Metab Syndr 2024; 16:154. [PMID: 38982536 PMCID: PMC11232319 DOI: 10.1186/s13098-024-01400-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 07/02/2024] [Indexed: 07/11/2024] Open
Abstract
OBJECTIVE Diabetic foot ulcer (DFU) is a common and debilitating complication of diabetes that is associated with an increased risk of lower-limb amputation and a reduced life expectancy. Tibial cortex transverse transport (TTT) has become a newly alternative surgical method to facilitate ulcer healing and prevent lower limb amputation. Herein, we investigated the efficacy of TTT in treating DFU and changes of serum omentin-1 and irisin levels. METHODS This study prospectively recruited 52 consecutive patients with DFU who were treated with TTT. The follow-up was performed weekly during the first 12 weeks postoperatively and every 3 months until 1 year after TTT. The serum levels of vascular endothelial growth factor (VEGF), omentin-1, and irisin in DFU patients undergoing TTT were determined by ELISA methods on the preoperative 1st day, postoperative 2nd week and 4th week. RESULTS The wound healing rate was 92.3% (48/52) at the 1-year follow-up. The visual analog scale (VAS) pain scores of patients showed a significant reduction at the 4th week after TTT (p < 0.001). The dorsal foot skin temperature, ankle brachial index, and dorsal foot blood flow of patients were significantly increased at the 4th week after TTT (p < 0.001). Results of ELISA methods showed the serum levels of VEGF, omentin-1, and irisin on the 2nd week and 4th week after TTT were notably elevated compared to the levels determined on the preoperative 1st day (p < 0.001). The serum levels of VEGF, omentin-1, and irisin on the 4th week after TTT were also significantly higher than the levels determined on the 2nd week after TTT (p < 0.001). CONCLUSION TTT could promote the wound healing and reduce the risk of lower limb amputation, demonstrating promising clinical benefits in the treatment of DFU. Increased expressions of serum proangiogenic factors including VEGF, omentin-1, and irisin were noted in the early stage after TTT, which may provide a new mechanism of TTT promoting wound heal.
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Affiliation(s)
- Yang Wen
- Orthopedic Center, Orthopaedic Trauma, Suining Central Hospital, No. 27 Dongping North Road, Hedong New District, Suining, 629000, Sichuan, China
| | - Liyuan Chen
- Medical Department, Suining Central Hospital, Suining, 629000, Sichuan, China
| | - Jiaping Lan
- Orthopedic Center, Orthopaedic Trauma, Suining Central Hospital, No. 27 Dongping North Road, Hedong New District, Suining, 629000, Sichuan, China
| | - Lei Li
- Orthopedic Center, Orthopaedic Trauma, Suining Central Hospital, No. 27 Dongping North Road, Hedong New District, Suining, 629000, Sichuan, China.
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Use of Recanalized Vessels for Diabetic Foot Reconstruction: Pushing the Boundaries of Reconstruction in a Vasculopathic Lower Extremity. Plast Reconstr Surg 2023; 151:485e-494e. [PMID: 36730343 DOI: 10.1097/prs.0000000000009935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Free flap after lower extremity revascularization may enable limb salvage in defects after critical limb ischemia. This study examined the outcomes of reconstruction of ischemic diabetic foot according to the severity of the vessel occlusion and assessed whether recanalized vessels may serve as a reliable recipient vessel. METHODS A total of 62 patients who underwent diabetic foot reconstruction with free flaps after successful percutaneous transluminal angioplasty (PTA) from February of 2010 to February of 2016 were identified and divided into three groups: group 1, nonoccluded vessels as recipient ( n = 11); group 2, recanalized artery after PTA for partially occluded artery ( n = 30); and group 3, recanalized artery after PTA for completely occluded artery ( n = 21). RESULTS Flap survival was statistically higher in group 2 (90%) compared with group 3 (67%) ( P < 0.05). Subsequent major amputation was significantly lower in groups 1 and 2 [0/7 and 1/30 (3.3%)] compared with group 3 [5/21 (23.8%)] ( P < 0.05). The patient survival and limb salvage rate was 90.9% at 1 and 3 years in group 1, 89.8% at 1 year and 86.3% at 3 and 5 years in group 2, and 76.2% at 1, 3, and 5 years in group 3. This difference was not statistically significant ( P = 0.485). CONCLUSIONS The use of recanalized vessels after PTA can be safe for partially occluded arteries but requires caution for completely occluded arteries. Using completely occluded vessels after PTA can be attempted when other options are not available and achieves a 76% chance of limb salvage. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Tan CH, Wu Y, Satkunanantham M. Flaps for lower limb diabetic wound reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2023; 79:74-86. [PMID: 36870103 DOI: 10.1016/j.bjps.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/29/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND The treatment of chronic diabetic wounds includes wound dressing, debridement, flap surgery, and amputation. For suitable patients with nonhealing wounds, locoregional flaps or free flaps may be used. This paper aims to review the outcomes of flap surgery and identify the risk factors for flap loss. METHODS MEDLINE, Embase, and Cochrane Library were searched. Articles reporting flap loss outcomes for flap surgery in lower limb chronic diabetic wounds were included. Case reports and case series with fewer than five patients were excluded. A subset of articles was used for revascularization subgroup analysis and another subset for meta-analysis of risk factors for flap loss. RESULTS In the free flap group, the total flap failure rate was 7.14% and partial flap failure rate was 7.54%. The rate of major complications requiring operative takeback was 19.0%. Early mortality was 2.76%. In the locoregional flap group, the total flap failure rate was 3.24% and partial flap failure rate was 5.36%. The rate of major complications requiring operative takeback was 13.3%. There was no early mortality. The rate of free flap loss was 18.2% with revascularization, significantly higher than 6.66% without revascularization. CONCLUSIONS Our findings concur with previously published studies on flap loss and complications in diabetic lower limb wounds. There is an increased risk of flap loss in patients who require free flap and revascularization compared to patients who only require free flap. This could be because of the fragile and fibrotic vessels found in diabetics with comorbid atherosclerosis.
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Affiliation(s)
| | | | - Mala Satkunanantham
- Department of Hand and Reconstructive Microsurgery, Tan Tock Seng Hospital, Singapore
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Effect of tibial cortex transverse transport in patients with recalcitrant diabetic foot ulcers: A prospective multicenter cohort study. J Orthop Translat 2022; 36:194-204. [PMID: 36263383 PMCID: PMC9576490 DOI: 10.1016/j.jot.2022.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/05/2022] [Accepted: 09/05/2022] [Indexed: 12/18/2022] Open
Abstract
Background Management of recalcitrant diabetic foot ulcer (DFU) remains difficult. Distraction osteogenesis mediates new bone formation and angiogenesis in the bone itself and the surrounding tissues. Recently it was reported that tibial cortex transverse transport (TTT) was associated with neovascularization and increased perfusion at the foot in patients with recalcitrant DFUs and facilitated healing and limb salvage. However, the findings were from several single-center studies with relatively small populations, which need to be confirmed in multicenter cohort studies with relatively large populations. Furthermore, the effect of this technique on patient's health-related quality of life is still unclear. Methods We treated patients with recalcitrant (University of Texas wound grading system 2-C to 3-D and not responding to prior routine conservative and surgical treatments for at least 8 weeks) DFUs from seven centers using TTT (a 5 cm × 1.5 cm corticotomy followed by 4 weeks of medial and lateral distraction) between July 2016 and June 2019. We analyzed ulcer healing, major amputation, recurrence, health-related quality of life (physical and mental component summary scores), and complications in the 2-year follow-up. Foot arterial and perfusion changes were evaluated using computed tomography angiography and perfusion imaging 12 weeks postoperatively. Results A total of 1175 patients were enrolled. Patients who died (85, 7.2%) or lost to follow-up (18, 1.7%) were excluded, leaving 1072 patients for evaluation. Most of the patients were male (752, 70.1%) and with a mean age of 60.4 ± 9.1 years. The mean ulcer size was 41.0 ± 8.5 cm2 and 187 (16.6%) ulcers extended above the ankle. During the follow-up, 1019 (94.9%) patients healed in a mean time of 12.4 ± 5.6 weeks, 53 (4.9%) had major amputations, and 33 (3.1%) experienced recurrences. Compared to preoperatively, the patients had higher physical (26.2 ± 8.3 versus 41.3 ± 10.6, p = 0.008) and mental (33.6 ± 10.7 versus 45.4 ± 11.3, p = 0.031) component summary scores at the 2-year follow-up. Closed tibial fracture at the corticotomy site was found in 8 (0.7%) patients and was treated using external fixation and healed uneventfully. There were 23 (2.1%) patients who had pin site infections and were treated successfully with dressing changes. Compared to preoperatively, the patients had more small arteries and higher foot blood flow (8.1 ± 2.2 versus 28.3 ± 3.9 ml/100 g/min, p = 0.003) and volume (1.5 ± 0.3 versus 2.7 ± 0.4 ml/100 g, p = 0.037) 12 weeks postoperatively. Conclusion TTT promotes healing, limb salvage, and health-related quality of life in patients with recalcitrant DFUs as demonstrated in this multicenter cohort study. The surgical procedure was simple and straightforward and the complications were few and minor. The effect of this technique was associated with neovascularization and improved perfusion at the foot mediated by the cortex distraction. The findings are required to confirm in randomized controlled trials.The Translational Potential of this Article: TTT can be used as an effective treatment in patients with recalcitrant DFUs. The mechanism is associated with neovascularization and consequently increased perfusion in the foot after operation.
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Microsurgical Strategies after Free Flap Failure in Soft Tissue Reconstruction of the Lower Extremity: A 17-Year Single-Center Experience. J Pers Med 2022; 12:jpm12101563. [PMID: 36294702 PMCID: PMC9604543 DOI: 10.3390/jpm12101563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/10/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background: There is no clear consensus on the optimal surgical strategy for providing safe coverage in salvage free flap surgery after total free flap failure. Methods: A retrospective study was conducted to evaluate patients with total failure of the primary free flap in lower extremity reconstruction between 2000 and 2017. Results: In a cohort of 1.016 patients, we identified 43 cases of total flap failure (4.2%). A total of 30 patients received a salvage free flap with a success rate of 83.3% (25/30). One patient received a secondary salvage free flap. Overall limb salvage after primary free flap loss was 83.7% (36/43). Conclusions: Microsurgical management of free flap loss in the lower extremity is challenging and requires a decisive re-evaluation of risk factors and alternative strategies. This should include reconsidering the flap choice with a tendency towards traditional and safe workhorse flaps, a low-threshold switch to different recipient vessels, including arteriovenous (AV) loops, bypasses (especially in case of venous insufficiency) and back-up procedures, such as negative pressure wound therapy or dermal regeneration templates with skin grafting in cases of lower demand and critically ill patients. We derived one suggestion from our previous practice: replacing perforator flaps with axial pattern flaps (“safe workhorses”).
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Sayyed AA, Towfighi P, Deldar R, Attinger CE, Evans KK. Free flap reconstruction of plantar weight-bearing heel defects: Long-term functional and patient-reported outcomes. Microsurgery 2022; 42:538-547. [PMID: 35394669 DOI: 10.1002/micr.30889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/28/2022] [Accepted: 03/30/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE Non-healing plantar weight-bearing heel ulcers are a challenging problem to treat. Free tissue transfer (FTT) reconstruction of the heel is an opportunity for limb salvage to preserve gait and ambulation. The aim of this study is to describe surgical and functional outcomes in patients who underwent FTT to treat chronic heel ulcers. METHODS A retrospective review of patients who underwent FTT for plantar heel ulcers from 2011 to 2021 was conducted. Patient demographics, comorbidities, perioperative data, postoperative complications, and long-term outcomes were recorded. Primary outcomes included flap success, complications, postoperative ambulation, patient-reported outcome measures and limb salvage, with patients stratified into limb salvage or eventual amputation groups. RESULTS Forty-four patients underwent 45 heel reconstructions. Average age and BMI were 57.3 years and 30.1 kg/m2 , respectively. Thirty-eight patients (86.4%) had calcaneal osteomyelitis, 35 patients (79.5%) had diabetes, and 18 patients (40.9%) had peripheral vascular disease (PVD). Immediate microsurgical success rate was 95.6%. At mean follow-up of 19.6 ± 20.9 months, overall limb salvage rate was 73.3% (n = 33). Preoperative albumin levels were higher in limb salvage group compared to the amputation group (3.0 vs. 2.4 g/dl, p = .018). Prior stroke history and hypoalbuminemia were significantly higher in the amputation group compared to limb salvage group (p = .012 and p = .018, respectively). Risk for eventual amputation was associated with PVD (OR 4.0, p = .053), hypoalbuminemia (OR 4.9, p = .020), and postoperative infection (OR 6.3, p = .013). Of the 12 amputations that occurred, the most common indication for amputation was infection (n = 8, 66.7%), which most often occurred at the original wound location (62.5%). At most recent follow-up, 90.7% of patients (n = 39) were ambulatory. CONCLUSION FTT is an effective alternative to amputation in patients with chronic heel ulcers. Proper patient selection, preoperative optimization, and postoperative care are imperative to the success of this limb salvage procedure.
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Affiliation(s)
- Adaah A Sayyed
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Parhom Towfighi
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Romina Deldar
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
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Kim KG, Tirrell AR, Dekker PK, Haffner Z, Attinger CE, Fan KL, Evans KK. The Need to Improve Patient-Centered Outcome Reporting Following Lower Extremity Flap Reconstruction: A Systematic Review and Meta-analysis. J Reconstr Microsurg 2021; 37:764-773. [PMID: 33853126 DOI: 10.1055/s-0041-1726398] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Research in lower extremity (LE) wound management involving flap reconstruction has primarily focused on surgeon-driven metrics. There has been a paucity in research that evaluates patient-centered outcomes (PCO). This systematic review and meta-analysis examines articles published between 2012 and 2020 to assess whether reporting of functional and quality of life (QOL) outcomes have increased in frequency and cohesiveness, compared with the previous two decades. METHODS PubMed and Ovid were queried with appropriate Medical Subject Heading (MeSH) terms for studies published between June 2012 and July 2020. For inclusion, each study had to report any outcome of any tissue transfer procedure to the LE in comorbid patients, including complication rates, ambulation rates, flap success rates, and/or QOL measures. The PCO reporting prevalence was compared with a previous systematic review by Economides et al which analyzed papers published between 1990 and June 2012, using a Pearson's Chi-squared test. RESULTS The literature search yielded 40 articles for inclusion. The proportion of studies reporting PCO was greater for literature published between 1990 and 2012 compared with literature published between 2012 and 2020 (86.0 vs. 50.0%, p < 0.001). Functional outcomes were more commonly reported between 1990 and 2012 (78.0 vs. 47.5%, p = 0.003); similarly, ambulatory status was reported more often in the previous review (70.0 vs. 40.0%, p = 0.004). This study solely examined the rate at which PCO were reported in the literature; the individual importance and effect on medical outcomes of each PCO was not evaluated. CONCLUSION Less than 50% of the literature report functional outcomes in comorbid patients undergoing LE flap reconstruction. Surprisingly, PCO reporting has seen a downward trend in the past 8 years relative to the preceding two decades. Standardized inclusion of PCO in research regarding this patient population should be established, especially as health care and governmental priorities shift toward patient-centered care.
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Affiliation(s)
- Kevin G Kim
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Abigail R Tirrell
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Paige K Dekker
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Zoe Haffner
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
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Lumley ES, Kwon JG, Kushida-Conteras BH, Brown E, Viste J, Aulia I, Pak CJ, Suh HP, Hong JP. Free Tissue Transfer after Open Transmetatarsal Amputation in Diabetic Patients. J Reconstr Microsurg 2021; 37:728-734. [PMID: 33792004 DOI: 10.1055/s-0041-1726394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Transmetatarsal amputation (TMA) preserves functional gait while avoiding the need for prosthesis. However, when primary closure is not possible after amputation, higher level amputation is recommended. We hypothesize that reconstruction of the amputation stump using free tissue transfer when closure is not possible can achieve similar benefits as primarily closed TMAs. METHODS Twenty-eight TMAs with free flap reconstruction were retrospectively reviewed in 27 diabetic patients with a median age of 61.5 years from 2004 to 2018. The primary outcome was limb salvage rate, with additional evaluation of flap survival, ambulatory status, time until ambulation, and further amputation rate. In addition, subgroup analysis was performed based on the microanastomosis type. RESULTS Flap survival was 93% (26 of 28 flaps) and limb salvage rate of 93% (25 of 27 limbs) was achieved. One patient underwent a second free flap reconstruction. In the two failed cases, higher level amputation was required. Thirteen flaps had partial loss or other complications which were salvaged with secondary intension or skin grafts. Median time until ambulation was 14 days following reconstruction (range: 9-20 days). Patients were followed-up for a median of 344 days (range: 142-594 days). Also, 88% of patients reported good ambulatory function, with a median ambulation score of 4 out of 5 at follow-up. There was no significant difference between the subgroups based on the microanastomosis type. CONCLUSION TMA with free flap reconstruction is an effective method for diabetic limb salvage, yielding good functional outcomes and healing results.
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Affiliation(s)
- Eleanor S Lumley
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea.,Department of Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Jin Geun Kwon
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | | | - Erin Brown
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea.,Department of Plastic Surgery, University of British Columbia, Canada
| | - Julian Viste
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Indri Aulia
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea.,Department of Surgery, Plastic Reconstructive and Aesthetic Surgery Division, Universitas Indonesia, Jakarta, Indonesia
| | - Changsik John Pak
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
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Kotsougiani-Fischer D, Fischer S, Warszawski J, Gruetzner PA, Reiter G, Hirche C, Kneser U. Multidisciplinary team meetings for patients with complex extremity defects: a retrospective analysis of treatment recommendations and prognostic factors for non-implementation. BMC Surg 2021; 21:168. [PMID: 33781250 PMCID: PMC8006355 DOI: 10.1186/s12893-021-01169-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background This study aimed to assess a multidisciplinary team (MDT) meeting approach for the management of patients with complex extremity defects, analyze treatment recommendations, and evaluate factors influencing non-implementation. Methods All patients introduced to an MDT meeting for complex extremity defects from 2015 to 2017 were included in a retrospective cohort study. Patients’ characteristics and defect causes were evaluated. Treatment recommendations (TR) of MDT meetings and subsequent implementation were reviewed (cohort with implementation of TR versus cohort with non-implementation of TR), and factors associated with non-adherence to recommendations were statistically analyzed using logistic regression. Results Fifty-one patients (41 male) with a mean age of 54 years were presented in 27 MDT meetings. Most of the patients (70%) suffered from reconstructive challenging or combined bone- and soft tissue defects, primarily located at the lower extremity (88%). Large skeletal defects, chronic osteomyelitis, and multi-fragmented fractures were present in 65% of cases. Forty-five percent of the patients suffered from peripheral vascular disease, necessitating surgical optimization. Of the 51 MDT decisions, 40 were implemented (78%; (32/40) limb salvage versus 22%; (8/40) limb amputation). Limb salvage was successfully achieved in 91% (29/32) of the cases. Failed limb salvages were due to flap failure (33%; 1/3), recurring periprosthetic joint infections (66%; 2/3) and concomitant reconstructive failure. Patients who underwent limb amputation, as recommended, showed proper stump healing and regained mobility with a prosthesis. Overall the MDT treatment plan was effective in 92.5% (37/40) of the patients, who adhered to the MDT treatment recommendation. In eleven patients (22%; 11/51), the MDT treatment was not implemented. MDT decisions were less likely to be implemented, if amputation was recommended (p = 0.029). Conclusions MDT meetings represent a valid tool to formulate individualized treatment plans, avoiding limb amputation in most patients with severe extremity defects. Recommendation for limb amputation is less likely to be implemented than plans for limb salvage. Trial registration: Retrospectively registered
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Affiliation(s)
- Dimitra Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany.
| | - Sebastian Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Jan Warszawski
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Paul A Gruetzner
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwig Gutmann Strasse 13, Ludwigshafen, 67071, Germany
| | - Gregor Reiter
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwig Gutmann Strasse 13, Ludwigshafen, 67071, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
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Thai DQ, Lee DH, Lee WB, Hahn HM, Lee IJ. What is the impact of infrapopliteal endovascular intervention on free flap survival in diabetic foot reconstruction? J Orthop Surg Res 2021; 16:42. [PMID: 33430921 PMCID: PMC7802144 DOI: 10.1186/s13018-020-02173-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/25/2020] [Indexed: 11/29/2022] Open
Abstract
Background The combination of endovascular intervention and microvascular free flap transfer has been effectively used for chronic ischemic wounds of lower limb. The aim of this study was to determine the influence of angioplasty on free flap survival in diabetic foot ulcer reconstruction. Methods A retrospective research was conducted for 46 diabetic patients with chronic ulcer of the foot. All patients underwent free flap reconstruction because of their non-healing wound with tendon or bone exposure. Patient’s demography, clinical data related to vascular status, vascular intervention, and free flap transfer procedure were collected. Flap survival rate was compared between the group with severe arterial stenosis group and non-severe stenosis group. It was also compared among groups with different revascularization results. Results The average age of patients was 56.2 ± 10.8 years. There were 14 (30.4%) men and 32 (69.6%) women. Of 46 patients, 23 (50%) had severe infrapopliteal arterial stenosis. All 23 patients underwent endovascular intervention. Their final results of the pedal arch were type 1 in 13 patients, type 2A in 7 patients, type 2B in 2 patients, and type 3 in 1 patient. Total flap necrosis was found in 5 (10.9%) cases, marginal necrosis in 4 (8.7%) cases, and wound dehiscence in 4 (8.7%) cases. There was no significant difference in flap loss between severe arterial stenosis patients and non-severe arterial stenosis patients. In the severe arterial stenosis group, after endovascular intervention, patients with type 1 of pedal arch had a significantly lower rate of total flap necrosis than others. There was no association between the use of revascularized recipient artery and flap survival. Conclusions Our study revealed that the quality of pedal arch was crucial for free flap survival. Thus, PTA should aim to re-establish a complete pedal arch to increase wound healing rate and flap success.
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Affiliation(s)
- Duy Quang Thai
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Dong Hwan Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Woo Beom Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Hyung Min Hahn
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Il Jae Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
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Zhang YW, Xiong LY, Gao WC, Deng L. Treatment of diabetic foot with the transverse tibial bone transport guided by three-dimensional printing guide plates. Asian J Surg 2020; 43:832-834. [PMID: 32245658 DOI: 10.1016/j.asjsur.2020.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Yuan-Wei Zhang
- Department of Orthopedics, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, Jiangxi, 330006, China; Medical Department of Graduate School, Nanchang University, Nanchang, Jiangxi, 330006, China
| | - Liang-Yu Xiong
- Department of Orthopedics, Zhangshu Municipal People's Hospital, Yichun, Jiangxi, 331200, China
| | - Wen-Cheng Gao
- Department of Orthopedics, Dongguan Houjie Town People's Hospital, Dongguan, Guangdong, 523900, China
| | - Liang Deng
- Department of Orthopedics, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, Jiangxi, 330006, China.
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12
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Godoy-Santos AL, Rosemberg LA, de Cesar-Netto C, Armstrong DG. The use of bioactive glass S53P4 in the treatment of an infected Charcot foot: a case report. J Wound Care 2019; 28:S14-S17. [PMID: 30724119 DOI: 10.12968/jowc.2019.28.sup1.s14] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE: To report a case of successful limb-salvage staged treatment in the treatment of an infected diabetic Charcot foot. CASE SUMMARY: A 45-year-old male with long-term, uncontrolled type 2 diabetes, six months' history of progressive deformity on the right foot and 45 days of purulent drainage in the lateral aspect of the foot. Patient was diagnosed with an infected Charcot foot with extensive midfoot bone involvement as shown by radiographic and MRI images. We used a multidisciplinary approach to treatment with early antibiotic therapy, tight glycaemic control and staged surgical treatment. Initial treatment was adequate irrigation and debridement, bone-void filling with bioactive glass, external fixation and provisional negative pressure wound therapy (NPWT). Later progressed to total contact casting and progressive protect weight bearing. At final follow-up, patient was full weight-bearing in stiff soled footwear, with no clinical signs of infection, no gross alteration of gait pattern and demonstrating complete bone healing and integration of the bioactive glass. CONCLUSION: The bioactive glass S53P4 was successfully used in the limb-salvage staged treatment of a patient with an infected Charcot foot. Here, full integration with the surrounding bone and its supportive action in the combat of bone infection was demonstrated.
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Affiliation(s)
- Alexandre L Godoy-Santos
- Department of Orthopedic Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, BR; and Departamento de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Laercio A Rosemberg
- Departamento de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil; and Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Cesar de Cesar-Netto
- Fellow of Department of Orthopedics Foot and Ankle, Hospital for Special Surgery, New York, NY, US
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, US
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Henn D, Bigdeli AK, Horsch M, Weiß C, Kühner C, Hirche C, Schmidt VJ, Kneser U. Venous bypass grafts versus arteriovenous loops as recipient vessels for microvascular anastomosis in lower extremity reconstructions: A matched‐pair analysis. Microsurgery 2019; 40:12-18. [DOI: 10.1002/micr.30428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/29/2018] [Accepted: 01/04/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Dominic Henn
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
| | - Miriam Horsch
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
| | - Christel Weiß
- Department of Medical StatisticsUniversity Medicine Mannheim, University of Heidelberg, Theodor‐Kutzer‐Ufer 1 Mannheim Germany
| | - Clemens Kühner
- Department of Vascular SurgeryLudwigshafen Hospital, Bremser Str. 79 Ludwigshafen Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
| | - Volker J. Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
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14
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Outcomes of endovascular treatment versus bypass surgery for critical limb ischemia in patients with thromboangiitis obliterans. PLoS One 2018; 13:e0205305. [PMID: 30300407 PMCID: PMC6177182 DOI: 10.1371/journal.pone.0205305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/21/2018] [Indexed: 11/23/2022] Open
Abstract
We aimed to compare the clinical outcomes between endovascular treatment and inframalleolar bypass surgery for critical limb ischemia (CLI) in patients with thromboangiitis obliterans (TAO) and to assess the role of bypass surgery in the era of innovative endovascular treatment. Between January 2007 and December 2017, a total of 33 consecutive patients with the diagnosis of TAO presenting with CLI who underwent endovascular treatment (endovascular group, n = 22) or bypass surgery to the pedal or plantar vessels (bypass group, n = 11) were included and analyzed retrospectively. The primary endpoint was defined as a major amputation of the index limb, and the secondary endpoint was defined as graft occlusion, regardless of the number of subsequent procedures. In the bypass group, six patients (55%) had undergone previous failed endovascular procedures and/or arterial bypass surgery to the index limb before inframalleolar bypass, and two patients (18%) received microvascular flap reconstruction after bypass surgery. During the median follow-up period of 32 months (range 1–115 months), there were no significant differences in primary and secondary endpoints between the two groups although the bypass group had a higher Rutherford class than the endovascular group. Kaplan–Meier survival analysis showed that there were similar limb salvage (P = 0.95) and graft patency rates (P = 0.39). In conclusion, endovascular treatment is a valid strategy leading to an acceptable limb salvage rate for TAO patients, and surgical bypass to distal target vessels could play a vital role in cases of previous failed endovascular treatment or extensive soft tissue loss of the foot.
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15
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Whiteley J, Chow T, Adissu H, Keating A, Rogers IM. Topical Application of Culture-Expanded CD34+ Umbilical Cord Blood Cells from Frozen Units Accelerates Healing of Diabetic Skin Wounds in Mice. Stem Cells Transl Med 2018; 7:591-601. [PMID: 29752867 PMCID: PMC6090513 DOI: 10.1002/sctm.17-0302] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/29/2018] [Indexed: 11/11/2022] Open
Abstract
Chronic and nonhealing wounds are constant health issues facing patients with type 2 diabetes. As the incidence of type 2 diabetes mellitus (T2DM) increases, the incidence of chronic wounds and amputations will rise. T2DM is associated with peripheral arterial occlusive disease, which leads to the development of nonhealing skin ulcers after minor trauma. Patients develop severe pain limiting their mobility and ability to work and take care of themselves, thus putting a significant burden on the family and society. CD34+ cells from umbilical cord blood (UCB) grown in fibroblast growth factor-4 (FGF-4), stem cell factor, and Flt3-ligand produced a population of cells that have the ability to proliferate and develop properties enabling them to enhance tissue regeneration. The goal of this study was to assess in vitro cultured CD34+ cells in a setting where they would eventually be rejected so we could isolate paracrine signaling mediated therapeutic effect from the therapeutic effect due to engraftment and differentiation. To achieve this, we used db/db mice as a model for diabetic skin ulcers. Here, we report that in vitro cultured UCB CD34+ cells from frozen units can accelerate wound healing and resulted in the regeneration of full thickness skin. This study demonstrates a new indication for banked UCB units in the area of tissue regeneration. Stem Cells Translational Medicine 2018;7:591-601.
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Affiliation(s)
- Jennifer Whiteley
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Theresa Chow
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto
| | - Hibret Adissu
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Armand Keating
- Krembil Research Institute, Cancer Clinical Research Unit (CCRU), Princess Margaret Cancer Centre, Cell Therapy Program, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Ian M Rogers
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto.,Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Toronto, Ontario, Canada
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16
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Kantar RS, Rifkin WJ, David JA, Cammarata MJ, Diaz-Siso JR, Levine JP, Golas AR, Ceradini DJ. Diabetes is not associated with increased rates of free flap failure: Analysis of outcomes in 6030 patients from the ACS-NSQIP database. Microsurgery 2018; 39:14-23. [PMID: 29719063 DOI: 10.1002/micr.30332] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/07/2018] [Accepted: 04/06/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Diabetes affects a significant proportion of the population in the United States. Microsurgical procedures are common in this patient population, and despite many conflicting reports in the literature, there are no large studies evaluating the direct association between diabetes and outcomes, specifically failure, following free flap reconstruction. In this study, we sought to determine the impact of diabetes on postoperative outcomes following free flap reconstruction using a national multi-institutional database. METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients undergoing free flap reconstruction from 2010 to 2015. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Univariate and multivariate analyses were performed to control for confounders. RESULTS We identified 6030 eligible patients. No significant difference in flap failure rates was observed. However, diabetic patients presented significantly higher rates of wound complications, including deep incisional surgical site infection (SSI) (OR = 1.35; P = .01) and wound dehiscence (OR = 1.17; P = .03). Diabetic patients also presented a significantly longer hospital length of stay (LOS) (β = .62; P < .001). CONCLUSIONS Our study evaluated the largest national cohort of free flap procedures. These results suggest that diabetes is not associated with increased rates of flap failure. However, diabetic patients are at significantly higher risk of postoperative deep incisional SSI, wound dehiscence, and longer LOS. Our findings provide the most concrete evidence to date in support of free flap reconstruction in diabetic patients, but highlight the need for heightened clinical vigilance and wound care for optimal outcomes.
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Affiliation(s)
- Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - William J Rifkin
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Joshua A David
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Michael J Cammarata
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - J Rodrigo Diaz-Siso
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Alyssa R Golas
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Daniel J Ceradini
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
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17
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Khoo R, Jansen S. Slow to heel: a literature review on the management of diabetic calcaneal ulceration. Int Wound J 2018; 15:205-211. [PMID: 29431291 PMCID: PMC7949754 DOI: 10.1111/iwj.12839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/08/2017] [Indexed: 12/19/2022] Open
Abstract
The diabetic heel ulcer (DHU) represents a reconstructive challenge to clinicians and the multidisciplinary team alike. It is traditionally viewed as a condition that is inherently difficult to treat due to the intrinsic anatomical vulnerabilities of the heel. In addition to this, several factors are associated with poorer end outcomes - namely, that of major amputation. These include peripheral vascular disease, infection/osteomyelitis and the size of the ulcer itself. In light of the significant morbidity, economic burden and mortality seen in this cohort of patients, this review aims to explore current treatment modalities that have been undertaken. Literature in this field has mostly been confined to a handful of small case studies, some of which reflect novel, multimodal approaches, and promising results. Management with osteotomy, flap reconstruction and acellular dermal matrices, amongst other options, is covered within this review.
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Affiliation(s)
- Rachel Khoo
- Department of Plastic and Reconstructive SurgeryFiona Stanley HospitalPerthWAAustralia
| | - Shirley Jansen
- Department of Vascular and Endovascular SurgerySir Charles Gairdner HospitalPerthWAAustralia
- Centre for Population Health ResearchCurtin UniversityPerthWAAustralia
- Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthWAAustralia
- Heart Research InstituteHarry Perkins Institute of Medical ResearchPerthWAAustralia
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Affiliation(s)
- Tomoya Sato
- Department of Plastic and Reconstructive Surgery, Saitama Medical University, Moroyama, Iruma-gun, Saitama, Japan
| | - Yuichiro Yana
- Department of Plastic and Reconstructive Surgery, Saitama Medical University, Moroyama, Iruma-gun, Saitama, Japan
| | - Shigeru Ichioka
- Department of Plastic and Reconstructive Surgery, Saitama Medical University, Moroyama, Iruma-gun, Saitama, Japan
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Godoy-Santos AL, Amodio DT, Pires A, Lima ALM, Wei TH, de Cesar-Netto C, Armstrong DG. Diabetic limb salvage procedure with bone allograft and free flap transfer: a case report. Diabet Foot Ankle 2017; 8:1270076. [PMID: 28326158 PMCID: PMC5328323 DOI: 10.1080/2000625x.2016.1270076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/27/2016] [Accepted: 11/28/2016] [Indexed: 11/23/2022]
Abstract
The aim of this case report was to describe a successful diabetic limb salvage procedure in the treatment of an infected diabetic foot ulcer through a multidisciplinary team approach and complex surgical reconstruction involving a femoral head bone allograft and musculocutaneous latissimus dorsi free flap. The decision to proceed with aggressive staged efforts at diabetic limb salvage should be made only after careful consultation with the patient, his or her family, and the rest of the multidisciplinary healthcare team.
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Affiliation(s)
| | - Daniel T Amodio
- Department of Orthopedic Surgery, Hospital do Coraçao , São Paulo , Brazil
| | - André Pires
- Department of Orthopedic Surgery, University of São Paulo , São Paulo , Brazil
| | - Ana L M Lima
- Department of Orthopedic Surgery, University of São Paulo , São Paulo , Brazil
| | - Teng H Wei
- Department of Orthopedic Surgery, University of São Paulo , São Paulo , Brazil
| | - Cesar de Cesar-Netto
- Department of Orthopedic Surgery, Medstar Union Memorial Hospital , Baltimore , MD , USA
| | - David G Armstrong
- Department of Surgery, The University of Arizona , Tucson , AZ , USA
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20
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Capobianco CM, Zgonis T. Soft Tissue Reconstruction Pyramid for the Diabetic Charcot Foot. Clin Podiatr Med Surg 2017; 34:69-76. [PMID: 27865316 DOI: 10.1016/j.cpm.2016.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Foot and ankle ulcerations in patients with diabetic Charcot neuroarthropathy (DCN) occur frequently and can be challenging to address surgically when conservative care fails. Patients with acute or chronic diabetic foot ulcers (DFU) are at continued risk for development of osteomyelitis, septic arthritis, gas gangrene, and potential lower extremity amputation. Concurrent vasculopathy and peripheral neuropathy as well as uncontrolled medical comorbidities complicate the treatment approach. In addition, pathomechanical forces left untreated may contribute to DFU recurrence in this patient population. This article outlines in detail the stepwise approach and options available for durable soft tissue coverage in the DCN patient.
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Affiliation(s)
- Claire M Capobianco
- Orthopaedic Associates of Southern Delaware, 1539 Savannah Road, Suite 203, Lewes, DE 19958, USA.
| | - Thomas Zgonis
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, MSC 7776, San Antonio, TX 78229, USA
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Long-term Results of Inframalleolar Bypass for Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2016; 52:815-822. [DOI: 10.1016/j.ejvs.2016.08.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 08/29/2016] [Indexed: 11/21/2022]
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22
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In situ eNOS/NO up-regulation-a simple and effective therapeutic strategy for diabetic skin ulcer. Sci Rep 2016; 6:30326. [PMID: 27453476 PMCID: PMC4958962 DOI: 10.1038/srep30326] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/04/2016] [Indexed: 01/04/2023] Open
Abstract
Decreased nitric oxide (NO) synthesis and increased NO consumption in diabetes induces the inadequate blood flow to tissues that is primarily responsible for the pathogenesis and refractoriness of diabetic skin ulcers. The present study proposed a simple and effective therapeutic strategy for diabetic skin ulcers—in situ up-regulation of endothelial nitric oxide synthase (eNOS) expression and NO synthesis by statin-loaded tissue engineering scaffold (TES). In vitro experiments on human umbilical vein endothelial cells indicated that the statin-loaded TES relieved the high-glucose induced decrease in cell viability and promoted NO synthesis under high-glucose conditions. In a rat model of diabetes, the statin-loaded TES promoted eNOS expression and NO synthesis in/around the regenerated tissues. Subsequently, accelerated vascularization and elevated blood supply were observed, followed by rapid wound healing. These findings suggest that the in situ up-regulation of eNOS/NO by a statin-loaded TES may be a useful therapeutic method for intractable diabetic skin wounds.
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Ruppert V. Commentary on 'strategies for free flap transfer and revascularisation with 10 year outcome in the treatment of large diabetic foot lesions'. Eur J Vasc Endovasc Surg 2015; 50:231. [PMID: 26070632 DOI: 10.1016/j.ejvs.2015.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 04/30/2015] [Indexed: 10/23/2022]
Affiliation(s)
- V Ruppert
- Department of Vascular Surgery, Klinikum Ingolstadt, Germany.
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