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Kavarthapu V, Giddie J, Kommalapati V, Casey J, Bates M, Vas P. Evaluation of Adjuvant Antibiotic Loaded Injectable Bio-Composite Material in Diabetic Foot Osteomyelitis and Charcot Foot Reconstruction. J Clin Med 2023; 12:jcm12093239. [PMID: 37176679 PMCID: PMC10179343 DOI: 10.3390/jcm12093239] [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: 02/20/2023] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023] Open
Abstract
The management of diabetic foot osteomyelitis (DFO) is extremely challenging with high amputation rates reported alongside a five-year mortality risk of more than fifty percent. We describe our experience in using adjuvant antibiotic-loaded bio-composite material (Cerament) in the surgical management of DFO and infected Charcot foot reconstruction. We undertook a retrospective evaluation of 53 consecutive patients (54 feet) who underwent Gentamicin or Vancomycin-loaded Cerament application during surgery. The feet were categorised into two groups: Group 1, with infected ulcer and DFO, managed with radical debridement only (n = 17), and Group 2, requiring reconstruction surgery for infected and deformed Charcot foot. Group 2 was further subdivided into 2a, with feet previously cleared of infection and undergoing a single-stage reconstruction (n = 19), and 2b, with feet having an active infection managed with a two-stage reconstruction (n = 18). The mean age was 56 years (27-83) and 59% (31/53) were males. The mean BMI was 30.2 kg/m2 (20.8-45.5). Foot ulcers were present in 69% (37/54) feet. At a mean follow-up of 30 months (12-98), there were two patients lost to follow up and the mortality rate was 11% (n = 5). The mean duration of post-operative systemic antibiotic administration was 20 days (4-42). Thirteen out of fifteen feet (87%) in group 1 achieved complete eradication of infection. There was a 100% primary ulcer resolution, 100% limb salvage and 76% bony union rate within Group 2. However, five patients, all in group 2, required reoperations due to problems with bone union. The use of antibiotic-loaded Cerament resulted in a high proportion of patients achieving infection clearance, functional limb salvage and decrease in the duration of postoperative antibiotic therapy. Larger, preferably randomised, studies are required to further validate these observations.
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Affiliation(s)
- Venu Kavarthapu
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Jasdeep Giddie
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Varun Kommalapati
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Joanne Casey
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Maureen Bates
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Prashanth Vas
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
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Robinson AHN, Garg P, Kirmani S, Allen P. The engagement of orthopaedic surgeons in diabetic foot care in England. Bone Jt Open 2022; 3:618-622. [PMID: 35909341 PMCID: PMC9422902 DOI: 10.1302/2633-1462.38.bjo-2022-0025.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England. Methods A questionnaire was sent to all 136 NHS trusts audited in the 2018 National Diabetic Foot Audit (NDFA). The questionnaire asked about the structure of diabetic foot care services. Results Overall, 123 trusts responded, of which 117 admitted patients with diabetic foot disease and 113 had an orthopaedic foot and ankle surgeon. A total of 90 trusts (77%) stated that the admission involved medicine, with 53 (45%) of these admissions being exclusively under medicine, and 37 (32%) as joint admissions. Of the joint admissions, 16 (14%) were combined with vascular and 12(10%) with orthopaedic surgery. Admission is solely under vascular surgery in 12 trusts (10%) and orthopaedic surgery in 7 (6%). Diabetic foot abscesses were drained by orthopaedic surgeons in 61 trusts (52%) and vascular surgeons in 47 (40%). Conclusion Orthopaedic surgeons make a significant contribution to both acute and elective diabetic foot care currently in the UK. This contribution is likely to increase with the movement of vascular surgery to a hub and spoke model, and measures should be put in place to increase the team based approach to the diabetic foot, for example with the introduction of a best practice tariff. Cite this article: Bone Jt Open 2022;3(8):618–622.
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Affiliation(s)
- A. H. N. Robinson
- Department of Trauma and Orthopaedics, Cambridge University Hospital NHS Trust, Cambridge, UK
| | - Parag Garg
- Department of Trauma and Orthopaedics, Cambridge University Hospital NHS Trust, Cambridge, UK
| | - Sayyied Kirmani
- Department of Trauma and Orthopaedics, Kettering General Hospital, Kettering, UK
| | - Patricia Allen
- Department of Orthopaedics, University Hospitals of Leicester NHS Trust Leicester General Hospital, Leicester, UK
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Vas PRJ, Whyte MB, Papanas N. Association between glycaemic control and diabetic foot outcomes: Dark side of the moon? J Diabetes Complications 2020; 34:107650. [PMID: 32571685 DOI: 10.1016/j.jdiacomp.2020.107650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 10/24/2022]
Affiliation(s)
- P R J Vas
- Department of Diabetes, King's College NHS Foundation Trust, London, United Kingdom; King's Health Partners' Institute of Diabetes, Endocrinology and Obesity, London, UK
| | - M B Whyte
- Department of Diabetes, King's College NHS Foundation Trust, London, United Kingdom; King's Health Partners' Institute of Diabetes, Endocrinology and Obesity, London, UK; Department of Clinical and Experimental Medicine, University of Surrey, United Kingdom
| | - N Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece.
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Chan CB, Dmytruk K, Labbie M, O’Connell P. Organizational changes in diabetic foot care practices for patients at low and moderate risk after implementing a comprehensive foot care program in Alberta, Canada. J Foot Ankle Res 2020; 13:26. [PMID: 32430079 PMCID: PMC7236492 DOI: 10.1186/s13047-020-00393-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/11/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Neuropathy and vasculopathy can lead to costly and debilitating complications in people with diabetes. The purpose of this study was to evaluate, at an organizational level, uptake of practices included in a diabetic foot care clinical pathway and associated resources. This research focused on patients at low and moderate risk in Alberta, Canada between 2014 to 2019. METHODS Serial surveys (2014, 2019) of practices related to screening and care of the feet of people with diabetes. Surveys were administered using a combination of targeted and snowball sampling in order to assess the impact of the clinical pathway first implemented in 2015. The pathway focused on screening, assessment and referral of patients from primary care. High-risk foot teams (HRFT) were established at six sites to provide increased access to specialty care. Comparative statistics were performed to assess differences in footcare practices between 2014 and 2019 using two-tailed Fisher's exact test or Chi-square test. RESULTS Respondents (n = 104, 2014 and n = 75, 2019) included personnel from primary health care, home care and long-term care, acute and emergency care, specialty clinics, diabetes-specific programs and private contractors. The proportion of primary care and home care/long-term care (HC/LTC) sites providing screening increased significantly (p < 0.05). A significant increase in the proportion of sites providing assessment for patients designated as moderate risk also increased from 35% (34 out of 96 sites) to 55% (36 out of 65 sites) (p < 0.05), particularly with respect to vascular assessment, and the proportion of sites reporting appropriate follow-up intervals according to the pathway recommendation was also improved. CONCLUSION Provision of a clinical pathway for diabetic foot care along with education and resources led to increased screening in primary care and HC/LTC settings in Alberta, Canada. HRFT provided primary healthcare providers with an important option for referral and also provided increased expertise for procedures such as vascular assessment for patients with moderate risk of ulceration. This comprehensive model has the potential to reduce progression of foot problems and overall health services utilization. Further analyses of outcomes such as incident lower limb amputation and long-term cost-effectiveness of pathway implementation are underway.
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Affiliation(s)
- Catherine B. Chan
- Diabetes, Obesity and Nutrition Strategic Clinical Network, Alberta Health Services, 10101 Southport Road, Calgary, Alberta T2W 1S7 Canada
- Department of Agricultural, Food and Nutritional Sciences, University of Alberta, 4-126 Li Ka Shing Centre, Edmonton, Alberta T6G 2E1 Canada
- Department of Physiology, University of Alberta, 7-55 Medical Sciences Building, Edmonton, Alberta T6G 2H7 Canada
| | - Kathy Dmytruk
- Diabetes, Obesity and Nutrition Strategic Clinical Network, Alberta Health Services, 10101 Southport Road, Calgary, Alberta T2W 1S7 Canada
| | - Michele Labbie
- WestView Health Centre, 4405 South Park Drive, Stony Plain, Alberta T7Z 2M7 Canada
| | - Petra O’Connell
- Diabetes, Obesity and Nutrition Strategic Clinical Network, Alberta Health Services, 10101 Southport Road, Calgary, Alberta T2W 1S7 Canada
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Sharma A, Vas P, Cohen S, Patel T, Thomas S, Fountoulakis N, Karalliedde J. Clinical features and burden of new onset diabetic foot ulcers post simultaneous pancreas kidney transplantation and kidney only transplantation. J Diabetes Complications 2019; 33:662-667. [PMID: 31301954 DOI: 10.1016/j.jdiacomp.2019.05.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients with diabetes and kidney disease are at risk of diabetes-related foot ulcers (DFU). Whether this risk is modified post simultaneous pancreas-kidney (SPK) or kidney only (KO) transplant is unknown. METHODS We evaluated the incidence of new onset DFU post SPK and KO transplant in 235 patients with diabetic kidney disease and diabetic neuropathy. In total 90 (51% male) SPK patients and 145 KO (66% male, 26% Type 1 DM) were evaluated in a single centre retrospective study. Median (range) follow up was 6 (3 to 13) years for both cohorts. RESULTS We observed that 16 (17%) of SPK and 22 (15%) KO patients respectively developed a DFU during follow up. In both cohorts a history of peripheral arterial disease [37.5% vs. 4%] and pre-transplant history of DFU were associated with post transplant DFU (p ≪ 0.05). In KO cohort, patients who developed a DFU were more likely to have T1DM than T2DM (29% vs. 10%), p ≪ 0.05. There was no impact of DFU on SPK transplant failure. In contrast patients with DFU post KO transplant had more than five fold increased hazard ratio (HR) of transplant failure as compared to those without DFU independent of other risk factors [HR 5.19 95% CI (2.05 to 13.18) p = 0.001]. CONCLUSION Nearly 1 in 7 patients develop a new onset DFU post KO or SPK transplantation and DFU also significantly increases risk of failure of the transplanted kidney. Our results highlight the need for greater awareness of regular foot examination, DFU prevention and risk evaluation in post-transplant patients. RESEARCH IN CONTEXT Evidence before this study Patients with diabetes and kidney disease are at enhanced risk of diabetic foot ulcers (DFU). Whether this risk is modified post successful kidney only (KO) or simultaneous pancreas and kidney (SPK) transplantation is unknown. Small case series and studies with short term follow up report varied rates of incidence and are from historical cohorts before the use of modern anti-transplant medications and treatments. Short term studies also suggest that post SPK the resultant normoglycaemia may reverse some features and risk markers of DFU. There are no long term studies on the incidence and impact of diabetic foot ulcers in patients with diabetic kidney disease post SPK or KO transplantation. Added value of this study We report the long term follow up results on DFU incidence, clinical features and related impact on transplant viability in 235 patients with diabetic kidney disease and neuropathy post successful SPK and KO transplant at a single centre. We observed that nearly 1 in 7 patients developed a DFU during follow up and that in patients who received KO transplant onset of DFU was associated with more than 5 fold increase of transplant failure. Implications of all the available evidence Our results highlight the need for greater awareness of regular foot examination, DFU prevention and risk evaluation in post-transplant patients. Despite normoglycaemia post SPK there is a residual burden and risk of DFU. Our work establishes a clinical rationale for further research to explore putative mechanisms that could explain the association between DFU and renal transplant dysfunction.
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Affiliation(s)
- Angelica Sharma
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Trust, London, UK; Department of Renal Medicine, Guy's and St Thomas' NHS Trust, London, UK; Department of Diabetes and Endocrinology, King's College Hospital, London, UK
| | - Prashanth Vas
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Trust, London, UK; Department of Renal Medicine, Guy's and St Thomas' NHS Trust, London, UK; Department of Diabetes and Endocrinology, King's College Hospital, London, UK.
| | - Siew Cohen
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Trust, London, UK; Department of Renal Medicine, Guy's and St Thomas' NHS Trust, London, UK; Department of Diabetes and Endocrinology, King's College Hospital, London, UK
| | - Tejal Patel
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Trust, London, UK; Department of Renal Medicine, Guy's and St Thomas' NHS Trust, London, UK; Department of Diabetes and Endocrinology, King's College Hospital, London, UK
| | - Stephen Thomas
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Trust, London, UK; Department of Renal Medicine, Guy's and St Thomas' NHS Trust, London, UK; Department of Diabetes and Endocrinology, King's College Hospital, London, UK
| | - Nikolaos Fountoulakis
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Trust, London, UK; Department of Renal Medicine, Guy's and St Thomas' NHS Trust, London, UK; Department of Diabetes and Endocrinology, King's College Hospital, London, UK
| | - Janaka Karalliedde
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Trust, London, UK; Department of Renal Medicine, Guy's and St Thomas' NHS Trust, London, UK; Department of Diabetes and Endocrinology, King's College Hospital, London, UK.
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Vas PRJ, Edmonds ME, Papanas N. Nutritional Supplementation for Diabetic Foot Ulcers: The Big Challenge. INT J LOW EXTR WOUND 2017; 16:226-229. [DOI: 10.1177/1534734617740254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Diabetic foot ulcers remain difficult to heal and nutritional supplementation may be an important complementary therapeutic measure. However, we need to clarify many issues before such supplementation is more widely used. Indeed, improvements are needed in the following areas: evaluation of nutritional inadequacy, completion of randomized controlled trials, understanding of patient and ulcer characteristics that favor response to nutritional supplementation, optimal duration of supplementation therapy, and evaluation of patient adherence. The challenge is now to acquire more knowledge in the aforementioned areas.
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Affiliation(s)
- R I G Holt
- Diabetic Medicine, University of Southampton
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