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Zou L, Wei Q, Pan S, Xiao F, Jiang Y, Zhong Y, Xie Y. Comparison of the Effects of Combined Femoral and Sciatic Nerves Block versus General Anesthesia on Hemodynamic Stability and Postoperative Complication in Patients with Diabetic Foot: A Prospective, Double-Blind and Randomized Controlled Trial. Diabetes Metab Syndr Obes 2024; 17:2243-2257. [PMID: 38854443 PMCID: PMC11162629 DOI: 10.2147/dmso.s465814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/30/2024] [Indexed: 06/11/2024] Open
Abstract
Background Perioperative anesthetic management of patients with diabetic foot undergoing surgical treatment is challenging due to their poor cardiovascular health status. According to previous literature, general anesthesia and peripheral nerve block have their own advantages and disadvantages for such patients. We reported the effect of these two anesthesia techniques on perioperative hemodynamics and prognosis in these patients. Methods This study employed a prospective randomized controlled design, where patients meeting the inclusion criteria were assigned to two groups: the general anesthesia group (GA group) and the peripheral nerve block group (PNB group). The primary outcomes were the differences in intraoperative hemodynamic stability and the incidence of postoperative complications between the two groups. The second outcomes were postoperative numerical rating scale scores, analgesic drug remedies, postoperative sleep conditions monitored by sleep bracelets and health status assessed by EQ-5D-5 L scores. Results One hundred and nine subjects were enrolled in this study, including 54 in the GA group and 55 in the PNB group. The baseline parameters of the two groups were comparable. The GA group exhibited a significantly higher incidence of hypotension, and Colloid intake and total fluid intake were significantly higher in the GA group than in the PNB group. Additionally, a larger proportion of patients in the GA group. The scores of postoperative pain during the 48 hours after surgery were significantly higher, and more patients needed tramadol for postoperative analgesia during the 24 h after surgery in the GA group than in the PNB group. Patients in the PNB group slept better, first feeding time, earlier out-of-bed activity and earlier discharge from the hospital, compared to the GA group. However, there was no obvious difference in postoperative complications between the two groups except pharyngeal pain. Conclusion Peripheral nerve block is a better option in patients with diabetes undergoing elective below-knee surgery than general anesthesia.
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Affiliation(s)
- Liyun Zou
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Qiufeng Wei
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Sining Pan
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Fei Xiao
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yage Jiang
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yu Zhong
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yubo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery After Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
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Grover P, Karuppan CM. The lower limb-loss rehabilitation continuum (LLRC) - a framework for program design and implementation. Disabil Rehabil 2024; 46:1652-1661. [PMID: 37147928 DOI: 10.1080/09638288.2023.2207221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 04/20/2023] [Indexed: 05/07/2023]
Abstract
Purpose: The multistep journey to prosthetic device-enabled functioning following amputation requires a structured approach for optimal care delivery, but such program structures and outcomes are inadequately characterized. The study is responsive by describing an implementation framework for lower limb loss rehabilitation and evaluating its utility.Materials and methods: The lower limb loss rehabilitation continuum framework (LLRC) was developed using literature-based continuum of care and amputation phase concepts as well as input from limb loss rehabilitation stakeholders. LLRC structure includes five sequential steps (Postsurgical Stabilization (PS), Preprosthetic Rehabilitation (PPR), Limb Healing and Maturation (LHM), Prosthetic Fitting (PF), Prosthetic Rehabilitation (PR)) between six touchpoints of patient-healthcare interaction (Surgery, Preprosthetic Rehabilitation Admission and Discharge, Functioning Evaluation and Prescription, Prosthetic Rehabilitation Admission and Discharge). The utility of this framework was evaluated through LLRC program implementation in a semiurban US setting and program functioning and process outcomes assessment from an IRB-approved, retrospective observational study about patients with unilateral lower-limb amputations completing this program.Results: Program functional (FIM gain; efficiency) scores were greater for PPR(32.6(8);3.1) compared with PR(24.3(8.5);3.8). Program completion duration was 149.7(63.4) days. LHM(75.8(58.5) days) and PF(51.4(24.3) days) were the longest steps. PR duration was significantly longer(p = 0.033) for the transfemoral level.Conclusion: The LLRC framework is useful for the design and implementation of structured limb loss rehabilitation programs.IMPLICATIONS FOR REHABILITATIONThe lower limb-loss rehabilitation continuum (LLRC) is a novel implementation framework with a five-step structure from limb loss to completion of prosthetic rehabilitation between six touchpoints of patient-healthcare interaction, with standardized terminology and baseline and outcome metrics. The utility of the program was demonstrated by successful program development in a suburban health setting and actionable process outcomes and superior functioning outcomes compared with literature.The LLRC can be adapted by health systems, institutions, and care providers for program development. Programs can expect high FIM gains and efficiency for Preprosthetic rehabilitation and Prosthetic rehabilitation steps. With an LLRC completion time of 5 months, long Limb healing and maturation and Prosthetic fitting steps present areas of opportunity for improvement.
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Affiliation(s)
- Prateek Grover
- Mercy Clinics and Mercy Rehabilitation Hospital, Springfield, MO, USA
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Essien SK, Zucker-Levin A. Comorbidity and risk factors of subsequent lower extremity amputation in patients diagnosed with diabetes in Saskatchewan, Canada. Chronic Illn 2023; 19:779-790. [PMID: 36366747 PMCID: PMC10655619 DOI: 10.1177/17423953221137891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/14/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Subsequent limb amputation (SLA) may be necessary due to disease progression, infection, or to aid prosthesis fit. SLA in Saskatchewan has increased 3.2% from 2006 to 2019 with minor SLA increasing 9.6% during that period. Diabetes affects a large proportion of patients who require SLA; however, the impact of additional comorbidities is not clear. METHODS First-episode subsequent lower extremity limb amputation (SLEA) cases with the presence/absence of diabetes, other comorbidities, and demographic characteristics from 2006-2019 were retrieved from Saskatchewan's Discharge Abstract Database. Logistic regression was performed to examine the magnitude of the odds of SLEA. RESULTS Among the 956 first-episode SLEA patients investigated, 78.8% were diagnosed with diabetes. Of these, 76.1% were male and 83.0% were aged 50 + years. Three comorbidities: renal failure (AOR = 1.9, 95% Cl 1.1 - 3.0), hypertension (AOR = 3.0, 95% Cl 2.0 - 4.5), and congestive heart failure (AOR = 2.0, 95% CI 1.2 - 3.2), conferred the highest odds of SLEA. The odds of SLEA is greatest for those aged 50-69 years, males, Registered Indians, and associated with a prolonged hospital stay. DISCUSSION These data are important as they may help medical providers identify patients at the highest risk of SLEA and target interventions to optimize outcomes.
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Affiliation(s)
- Samuel Kwaku Essien
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Canada
| | - Audrey Zucker-Levin
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Canada
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Yammine K, Otayek J, Haikal E, Daher M, El Alam A, Boulos K, Assi C. Analysis of systemic risk factors between diabetic/vascular patients having primary lower limb amputations and re-amputations. Vascular 2023:17085381231194964. [PMID: 37552100 DOI: 10.1177/17085381231194964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Background: Patients with diabetes mellitus (DM) are known to be predisposed to many complications in the lower extremities such as neuropathy, peripheral artery disease (PAD) and infection. Diabetic foot ulcers are complications of diabetes that can lead to lower extremity amputations, re-amputations and high mortality rates.Purpose: The aim of this study is to evaluate the risk factors associated with higher re-amputation rates in diabetic foot disease.Research Design: This is a mono-centric retrospective comparative study.Study Sample: the study included 136 patients, with a total of 193 procedures (111 primary amputations and 82 re-amputations) between 2011 and 2021.Data Analysis: The t-student test and Spearman correlation were used to look for mean differences and any relevant association, respectively. Multivariate logistic regression analysis was computed to look for independent variables.Results: Twenty-two (27%) and 60 (50%) of those who had major and minor amputations, respectively, had a re-amputation (p = 0.006). Besides diabetes (89%), the commonest risk factor associated with amputation was hypertension (86.7%), be it for primary amputation or re-amputation, followed by peripheral (PAD) and coronary artery diseases. Only three risk factors showed independent correlation with re-amputation; chronic kidney disease (r = 15%, p = 0.03), smoking (r = 15%, p = 0.03), and simultaneous presence of DM + PAD (r = 13.7%, p = 0.05).Conclusions: Factors that were significantly correlated with increased re-amputation rates have a clear pathologic pathway that affects vascularity and wound healing. Further studies should be aimed at developing a clear scoring system that can be used to stratify patient for re-amputation risk, and to better predict the results according to the severity of diabetes.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
- Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
| | - Joeffroy Otayek
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Emil Haikal
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Mohammad Daher
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Anthony El Alam
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Karl Boulos
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
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McNeil S, Waller K, Poy Lorenzo YS, Mateevici OC, Telianidis S, Qi S, Churilov I, MacIsaac RJ, Galligan A. Detection, management, and prevention of diabetes-related foot disease in the Australian context. World J Diabetes 2023; 14:942-957. [PMID: 37547594 PMCID: PMC10401446 DOI: 10.4239/wjd.v14.i7.942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/06/2023] [Accepted: 05/23/2023] [Indexed: 07/12/2023] Open
Abstract
Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.
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Affiliation(s)
- Scott McNeil
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Kate Waller
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Podiatry, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Yves S Poy Lorenzo
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Infectious Diseases Unit, Department of Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Pharmacy, St Vincent’s Hospital Melbourne, Fitzroy 3065, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
| | - Olimpia C Mateevici
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Infectious Diseases Unit, Department of Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Stacey Telianidis
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Sara Qi
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Irina Churilov
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Rehabilitation Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Richard J MacIsaac
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
- the Australian Centre for Accelerating Diabetes Innovations, School of Medicine, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Anna Galligan
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
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Anwander H, Vonwyl D, Hecht V, Tannast M, Kurze C, Krause F. Risk Factors for Failure After Surgery in Patients With Diabetic Foot Syndrome. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231182656. [PMID: 37435393 PMCID: PMC10331347 DOI: 10.1177/24730114231182656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background In the present study, we aimed to identify risk factors for failure (defined as reoperation within 60 days) after debridement or amputation at the lower extremity in patients with diabetic foot syndrome and to develop a model using the significant risk factors to predict the success rate at different levels of amputation. Methods Between September 2012 and November 2016, we performed a prospective observational cohort study of 174 surgeries in 105 patients with diabetic foot syndrome. In all patients, debridement or the level of amputation, need for reoperation, time to reoperation, and potential risk factors were assessed. A cox regression analysis, dependent on the level of amputation, with the endpoint reoperation within 60 days defined as failure and a predictive model for the significant risk factors were conducted. Results We identified the following 5 independent risk factors: More than 1 ulcer (hazard ratio [HR] 3.8), peripheral artery disease (PAD, HR 3.1), C-reactive protein >100 mg/L (HR 2.9), diabetic peripheral neuropathy (HR 2.9), and nonpalpable foot pulses (HR 2.7) are the 5 independent risk factors for failure, which were identified. Patients with no or 1 risk factor have a high success rate independent of the level of amputation. A patient with up to 2 risk factors undergoing debridement will achieve a success rate of <60%. However, a patient with 3 risk factors undergoing debridement will need further surgery in >80%. In patients with 4 risk factors a transmetatarsal amputation and in patients with 5 risk factors a lower leg amputation is needed for a success rate >50%. Conclusion Reoperation for diabetic foot syndrome occurs in 1 of 4 patients. Risk factors include presence of more than 1 ulcer, PAD, CRP > 100, peripheral neuropathy, and nonpalpable foot pulses. The more risk factors are present, the lower the success rate at a certain level of amputation. Level of Evidence Level II, prospective observational cohort study.
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Affiliation(s)
- Helen Anwander
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Vonwyl
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Verena Hecht
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Christophe Kurze
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Krause
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Choi Y, Lee HS, Kim JW, Lee BS, Lee WJ, Jung HG. Analysis of repeated lesions after diabetic forefoot amputation. Diabetes Res Clin Pract 2022; 190:109992. [PMID: 35842029 DOI: 10.1016/j.diabres.2022.109992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 11/03/2022]
Abstract
AIM This study was performed to analyze the clinical characteristics, related factors, and prognosis of repeated lesions after diabetic forefoot amputation. METHODS The medical records of 998 patients who underwent forefoot amputation because of their diabetic feet from March 2002 to February 2021 were retrospectively analyzed. Of the 508 selected patients with a follow-up period of at least 6 months, 288 had repeated lesions in the forefoot, and 220 did not have repeated lesions. The related factors of repeated lesions were compared and analyzed. Of the patients with repeated lesions, 142 and 104 on the ipsilateral and contralateral sides, respectively were also compared and examined. RESULTS Repeated lesions were statistically significant in diabetic polyneuropathy, vascular calcification, and dialysis. However, the anatomical positions of diabetic foot lesions, causes of lesions, anatomical amputation levels, number of surgeries, and management duration had no significant differences. Contralateral lesions occurred 8 months later than ipsilateral lesions, but reamputation above the Lisfranc joint was more frequent and prognosis was poorer. CONCLUSIONS Repeated lesions were affected by general conditions, and the contralateral side must be carefully examined after diabetic forefoot amputation.
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Affiliation(s)
- Youngrak Choi
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Ho Seong Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea.
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Bum-Sik Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Woo Je Lee
- Asan Diabetes Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Hong-Geun Jung
- Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul 05030, Republic of Korea
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