1
|
Huffman SS, Berger LE, Spoer DL, Marable JK, Ford AD, Yamamoto RK, Evans KK, Attinger CE. Utilizing the Frailty Index to Predict Long-term Mortality in Patients Undergoing Major Lower Extremity Amputation. J Foot Ankle Surg 2024:S1067-2516(24)00147-9. [PMID: 38960032 DOI: 10.1053/j.jfas.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 06/06/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024]
Abstract
The 5-factor modified Frailty Index (mFI-5) is a risk-stratification tool utilized to predict complications and mortality following major lower extremity (LE) amputation. However, its prognostic value for long-term mortality is unknown. The study aim was to assess whether a high mFI-5 score relates to long-term mortality following major LE amputation for chronic wounds. Patients ≥60 years who underwent major LE amputation from 2017 to 2021 were retrospectively reviewed. Data regarding demographics, comorbidities, perioperative factors, amputation type, and postoperative complications was collected and mFI-5 was calculated. Survival analysis was performed with Kaplan-Meier curves and differences were assessed with Log-Rank test. A total of 172 patients were identified. Mean age was 70.7 ± 8.0 years. Median time to ambulation was 3.7 months (IQR 4.0). By final follow-up of 17.5 ± 15.9 months, ambulatory rate was 51.7% (n = 89), overall mortality 36.0% (n = 62), 1-year mortality 14.0% (n = 24), and 3-year mortality 27.9% (n = 48). Patients with an mFI-5 of ≥4 (26.7%, n = 46) compared with patients with mFI-5 <4 (73.3%, n = 126) had a higher rate of prolonged postoperative LOS (34.8% vs 19.8%, p = .042), overall mortality (52.2% vs 30.2%, p = .008), 1-year mortality (23.9% vs 10.3%, p = .023), and 3-year mortality (45.7% vs 21.4%, p = .002). Multivariate analysis demonstrated mFI-5 was an independent predictor of 3-year mortality (OR 2.35, p = .043). At a threshold ≥4, the mFI-5 demonstrated utility in predicting long-term mortality. The value of this prognostic indicator is in its preoperative application of assessing risk of mortality, which should be utilized in conjunction with other measures.
Collapse
Affiliation(s)
- Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC; Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC; Georgetown University School of Medicine, Washington, DC
| | | | - Avery D Ford
- Georgetown University School of Medicine, Washington, DC
| | | | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC.
| |
Collapse
|
2
|
Vuorlaakso M, Karèn V, Kiiski J, Lahtela J, Kaartinen I. Multidisciplinary management of diabetic foot infection associated with improved 8-year overall survival. J Diabetes Complications 2024; 38:108719. [PMID: 38574694 DOI: 10.1016/j.jdiacomp.2024.108719] [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: 10/25/2023] [Revised: 02/05/2024] [Accepted: 02/29/2024] [Indexed: 04/06/2024]
Abstract
AIMS Diabetic foot syndrome is a global challenge best managed through multidisciplinary collaboration. This study aimed to investigate the effect of a systematic multidisciplinary team (MDT) on the overall survival and major amputation-free survival of hospitalized patients with diabetic foot infection (DFI). METHODS This retrospective cohort study was conducted at Tampere University Hospital. Cohorts of hospitalized patients with DFI before and after the initiation of multidisciplinary wound ward were compared after an 8-year follow-up. RESULTS Kaplan-Meier analysis revealed significantly higher overall survival in the post-MDT cohort (37.8 % vs 22.6 %, p < 0.05) in 8-year follow-up. Similarly, major amputation-free survival was superior in this cohort (31.8 % vs 16.9 %, p < 0.05). Additionally, early major amputation was associated with inferior overall survival (35.1 % vs 12.0 %, p < 0.05). In a multivariable Cox-regression analysis cohort (hazard ratio [HR] 1.38, 95 % confidence interval [CI95%] 1.01-1.87), early amputation (HR 1.64, CI95% 1.14-2.34) and diagnosed peripheral artery disease (HR 2.23, CI95% 1.61-3.09), congestive heart failure (HR 2.13, CI95% 1.47-3.08), or moderate kidney disease (HR 1.95, CI95% 1.34-2.84) were identified as significant risk factors affecting overall survival. CONCLUSIONS After systematic MDT approach we found improved long-term overall and major amputation-free survival. Multidisciplinary approach is therefore highly recommended for managing patients hospitalized for DFI.
Collapse
Affiliation(s)
- Miska Vuorlaakso
- Department of Musculoskeletal Surgery and Diseases, Clinic of Plastic and Reconstructive Surgery, Tampere University Hospital, Pirkanmaa Hospital District, PO Box 2000, FI-33521 Tampere, Finland.
| | - Verna Karèn
- Department of Musculoskeletal Surgery and Diseases, Clinic of Plastic and Reconstructive Surgery, Tampere University Hospital, Pirkanmaa Hospital District, PO Box 2000, FI-33521 Tampere, Finland.
| | - Juha Kiiski
- Department of Musculoskeletal Surgery and Diseases, Clinic of Plastic and Reconstructive Surgery, Tampere University Hospital, Pirkanmaa Hospital District, PO Box 2000, FI-33521 Tampere, Finland.
| | - Jorma Lahtela
- Department of Internal Medicine, Tampere University Hospital, Pirkanmaa Hospital District, PO Box 2000, FI-33521 Tampere, Finland.
| | - Ilkka Kaartinen
- Department of Musculoskeletal Surgery and Diseases, Clinic of Plastic and Reconstructive Surgery, Tampere University Hospital, Pirkanmaa Hospital District, PO Box 2000, FI-33521 Tampere, Finland.
| |
Collapse
|
3
|
Waibel FWA, Uçkay I, Soldevila-Boixader L, Sydler C, Gariani K. Current knowledge of morbidities and direct costs related to diabetic foot disorders: a literature review. Front Endocrinol (Lausanne) 2024; 14:1323315. [PMID: 38298183 PMCID: PMC10829909 DOI: 10.3389/fendo.2023.1323315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/29/2023] [Indexed: 02/02/2024] Open
Abstract
Diabetes is a chronic disease associated with numerous complications including diabetic foot disorders, which are associated with significant morbidity and mortality as well as high costs. The costs associated with diabetic foot disorders comprise those linked to care (direct) and loss of productivity and poor quality of life (indirect). Due to the constant increase in diabetes prevalence, it is expected that diabetic foot disorder will require more resources, both in terms of caregivers and economically. We reviewed findings on management, morbidity, mortality, and costs related to diabetic foot disorder.
Collapse
Affiliation(s)
- Felix W. A. Waibel
- Orthopaedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Ilker Uçkay
- Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Laura Soldevila-Boixader
- Infectious Diseases, Internal Medicine Department, Consorci Sanitari Integral-CSI, Sant Joan Despí Hospital, Barcelona, Spain
| | - Christina Sydler
- Orthopaedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karim Gariani
- Service of Endocrinology, Diabetes, Nutrition, and Therapeutic Education, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
- Diabetes Center of the Faculty of Medicine, University of Geneva Medical School, Geneva, Switzerland
| |
Collapse
|
4
|
Jung WH, Kim HY. Promoting foot self-care in type 2 diabetes mellitus patients receiving hemodialysis based on the information-motivation-behavioral skills model. Nurs Health Sci 2023; 25:721-731. [PMID: 38016930 DOI: 10.1111/nhs.13067] [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: 08/11/2022] [Revised: 10/12/2023] [Accepted: 10/31/2023] [Indexed: 11/30/2023]
Abstract
This study develops and verifies the use of the foot self-care behavioral model in patients with type 2 diabetes mellitus (T2DM) receiving hemodialysis (HD) based on the information-motivation-behavioral skills model. Data were collected between June and August 2021 from 156 outpatients with type 2 diabetes who were receiving regular HD. A structured questionnaire and electronic medical records were used to collect demographic and disease-related data along with Foot Care Knowledge Questionnaires, third version of Diabetes Attitude Scale, Multidimensional Scale of Perceived Social Support, Foot Care Confidence Scale, and Foot Self-care Behavior Scale. Age, diabetic foot care knowledge, social support, and foot care self-efficacy had a direct effect on foot self-care behavior. Foot care self-efficacy had a mediating effect on foot care knowledge, diabetes-related attitudes, social support, and foot self-care behavior. The information-motivation-behavioral skills model was suitable as a foot self-care behavioral model for patients with T2DM receiving HD. Additionally, these findings suggest that it is crucial to improve foot self-care behavior through increased foot care knowledge, diabetes-related attitudes, and social support, which could contribute to enhancing foot care self-efficacy.
Collapse
Affiliation(s)
- Won Hee Jung
- College of Nursing, Jeonbuk National University, Jeonju, Republic of Korea
| | - Hye Young Kim
- College of Nursing, Research Institute of Nursing Science, Jeonbuk National University, Jeonju, Republic of Korea
| |
Collapse
|
5
|
Manewell SM, Rao P, Haneman K, Zheng M, Charaf H, Menz HB, Sherrington C, Paul SS. Prevention and management of foot and lower limb health complications in adults undergoing dialysis: a scoping review. J Foot Ankle Res 2023; 16:81. [PMID: 37986004 PMCID: PMC10659051 DOI: 10.1186/s13047-023-00679-z] [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: 07/26/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Foot and lower limb health complications are common among patients undergoing dialysis; but a summary of prevention and management evidence is not available. The aim of this scoping review was to summarise study characteristics and the nature of results regarding strategies to prevent and manage peripheral arterial disease (PAD), foot ulceration, amputation, associated infection and associated hospital admission in adults undergoing dialysis. METHODS MEDLINE, Embase, CINAHL and AMED databases were searched for longitudinal experimental and observational studies. Eligible studies included adults undergoing dialysis (≥10 dialysis patients, with separate results or ≥ 75% of the cohort). Any interventions relating to PAD, foot ulceration, amputation, associated infection, and associated hospital admission were included. RESULTS The review included 212 studies, of which 199 were observational (94%) and 13 were experimental (6%). Sixteen studies (8%) addressed the prevention of foot and lower limb health complications, 43 (20%) addressed management, and 153 (72%) addressed both. The main intervention type in each study was surgery (n = 159, 75%), care from one or more health professionals (n = 13, 6%), screening by a health professional (n = 10, 5%), medication (n = 9, 4%) and rehabilitation (n = 5, 2%). No studies were identified where exercise, offloading or education were the main intervention. Results for PAD were reported in 137 (65%) studies, foot ulceration in 54 (25%), amputation in 171 (81%), infection in 7 (3%), and admission in 26 studies (12%). Results for more than one foot or lower limb outcome were reported in 141 studies (67%), with each study reporting on average two outcomes. Results varied and spanned positive, negative, and neutral outcomes following intervention. CONCLUSIONS Identified studies frequently aimed to both prevent and manage foot and lower limb health complications. A variety of interventions were identified and studies often reported results for more than one foot or lower limb health outcome. Findings from this review can be used to guide future research, with a goal to support improved patient outcomes.
Collapse
Affiliation(s)
- Sarah M Manewell
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, NSW, Camperdown, Australia.
- Podiatry Department, Sydney Local Health District, NSW Health, Camperdown, Australia.
| | - Purnima Rao
- Podiatry Department, Sydney Local Health District, NSW Health, Camperdown, Australia
| | - Keren Haneman
- Podiatry Department, Sydney Local Health District, NSW Health, Camperdown, Australia
| | - Minjia Zheng
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Camperdown, Australia
| | - Hady Charaf
- Faculty of Podiatric Medicine, School of Health Sciences, Western Sydney University, NSW, Campbelltown, Australia
| | - Hylton B Menz
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Cathie Sherrington
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney/Sydney Local Health District, NSW, Camperdown, Australia
| | - Serene S Paul
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, NSW, Camperdown, Australia
| |
Collapse
|
6
|
Berger LE, Shin S, Haffner ZK, Huffman SS, Spoer DL, Sayyed AA, Franzoni G, Bekeny JC, Attinger CE, Kleiber GM. The application of targeted muscle reinnervation in lower extremity amputations: A systematic review. Microsurgery 2023; 43:736-747. [PMID: 36864779 DOI: 10.1002/micr.31030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/09/2023] [Accepted: 02/17/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Targeted muscle reinnervation (TMR) is a promising surgical modality for reducing post-amputation pain. We sought to provide a succinct overview of TMR specific to the lower extremity (LE) amputation population. METHODS A systematic review was performed per PRISMA guidelines. Ovid MEDLINE, PubMed, and Web of Science were queried for records using various combinations of Medical Subject Heading (MeSH) terms such as "LE "amputation," "below-knee amputation" (BKA), "above-knee amputation" (AKA), and "TMR." Primary outcomes included (1) operative techniques, (2) changes in neuroma, phantom limb pain (PLP), or residual limb pain (RLP), and (3) postoperative complications. Studies were only included if outcomes data were discretely provided for LE patients. RESULTS Eleven articles examining 318 patients were identified. Average patient age was 47.5 ± 9.3 years, and most patients were male (n = 246, 77.4%). Eight manuscripts (72.7%) described TMR at the index amputation. The average number of nerve transfers performed per TMR case was 2.1 ± 0.8, and the most commonly employed nerve was the tibial (178/498; 35.7%). Nine (81.8%) articles incorporated patient-reported outcomes after TMR, with common methods including the Numerical Rating Scale (NRS) and questionnaires. Four studies (33.3%) reported functional outcomes such as ambulation ability and prosthesis tolerance. Complications were described in seven manuscripts (58.3%), with postoperative neuroma development being the most common (21/371; 7.2%). CONCLUSIONS The application of TMR to LE amputations is effective in reducing PLP and RLP with limited complications. Continued investigations are warranted to better understand patient outcomes specific to anatomic location using validated patient-reported outcome measures (PROM).
Collapse
Affiliation(s)
- Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, United States
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Stephanie Shin
- Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - Zoë K Haffner
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, United States
- Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, United States
- Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, United States
- Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - Adaah A Sayyed
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, United States
- Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - Garrett Franzoni
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, United States
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, United States
| | - Grant M Kleiber
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, United States
| |
Collapse
|
7
|
Chen L, Sun S, Gao Y, Ran X. Global mortality of diabetic foot ulcer: A systematic review and meta-analysis of observational studies. Diabetes Obes Metab 2023; 25:36-45. [PMID: 36054820 DOI: 10.1111/dom.14840] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022]
Abstract
AIM To estimate the long-term mortality and risk factors in patients with diabetic foot ulcer (DFU). METHODS We systematically searched Medline (PubMed), Embase, Scopus, Web of Science, Cochrane Library, China Science and Technology Journal Database (CQVIP), China National Knowledge Infrastructure, the Chinese Biomedical Literature Database (SinoMed) and Wanfang Data from 1 January 2011 to 31 July 2022. All observational studies that reported long-term mortality of patients with DFU were included. Random effect models were used to pool the reconstructed participant data from Kaplan-Meier curves. The primary outcome was the long-term survival of patients with DFU. An aggregate data meta-analysis was also performed. RESULTS We identified 34 studies, with 124 376 participants representing 16 countries, among whom there were 51 386 deaths. Of these, 27 studies with 21 171 patients were included in the Kaplan-Meier-based meta-analysis. The estimated Kaplan-Meier-based survival rates were 86.9% (95% confidence interval [CI] 82.6%-91.5%) at 1 year, 66.9% (95% CI 59.3%-75.6%) at 3 years, 50.9% (95% CI 42.0%-61.7%) at 5 years and 23.1% (95% CI 15.2%-34.9%) at 10 years. The results of the aggregate data-based meta-analysis were similar. Cardiovascular disease and infection were the most common causes of death, accounting for 46.6% (95% CI 33.5%-59.7%) and 24.8% (95% CI 16.0%-33.5%), respectively. Patients with older age (per 1 year, hazard ratio [HR] 1.054, 95% CI 1.045-1.063), peripheral artery disease (HR 1.882, 95% CI 1.592-2.225), chronic kidney disease (HR 1.535, 95% CI 1.227-1.919), end-stage renal disease (HR 3.586, 95% CI 1.333-9.643), amputation (HR 2.415, 95% CI 1.323-4.408) and history of cardiovascular disease (HR 1.449, 95% CI 1.276-1.645) had higher mortality risk. CONCLUSIONS This meta-analysis found that the overall mortality of DFU was high, with nearly 50% mortality within 5 years. Cardiovascular disease and infection were the two leading causes of death.
Collapse
Affiliation(s)
- Lihong Chen
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Shiyi Sun
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Yunyi Gao
- Department of Medical Affairs, West China Hospital, Sichuan University, Chengdu, China
| | - Xingwu Ran
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
8
|
Pittam B, Chumber R, Vashisht G, Miller S, O'Dowd C, Ledson T, Srinivas-Shankar U. The value of administering intravenous antibiotics during haemodialysis in the treatment of diabetic foot infections. J Wound Care 2022; 31:683-688. [PMID: 36001702 DOI: 10.12968/jowc.2022.31.8.683] [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: 11/11/2022]
Abstract
OBJECTIVE People with diabetes who are on haemodialysis (HD) are at a high risk of diabetic foot infections (DFI) and related complications. We explored the value of treating DFI with intravenous (IV) antibiotics during HD. METHOD This was an observational study of consecutively treated patients with DFIs with IV antibiotics during HD. Data collected included baseline characteristics, IV antibiotics used, details of multidisciplinary interventions and DFI treatment outcome. RESULTS A cohort of 11 patients, mean (±standard deviation) age 62.4±12.7 years, had 15 episodes of treatment with IV antibiotics during HD. Of the patients, six (54.5%) were male and nine (81.8%) had type 2 diabetes. The estimated mean glomerular filtration rate (eGFR) was 11.4±3.9ml/minute. All patients had infected foot ulceration, soft tissue infection, six (54.5%) patients had osteomyelitis, and two (18.2%) had wet gangrene. The commonest IV antibiotic used was vancomycin (10/15 episodes, 66.7%). Other IV antibiotics used were daptomycin and meropenem. In three episodes, oral ciprofloxacin was used with IV antibiotics. The mean duration of antibiotic treatment was 9.2±4.9 weeks. Of the episodes, 11 (73.3%) were treated successfully with IV antibiotics alone and two (13.3%) episodes required minor surgical debridement/amputation. Some 10 (90.9%) members of the cohort had peripheral arterial disease and of those, five (50%) underwent angioplasty during IV antibiotic treatment. CONCLUSION HD provides a good opportunity for treatment with IV antibiotics in DFI. This mode of administration of IV antibiotics, along with multidisciplinary intervention, is associated with ulcer healing and resolution of infection in over three-quarters of patients with DFI. DECLARATION OF INTEREST The authors have no conflicts of interest to declare.
Collapse
Affiliation(s)
- Bradley Pittam
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Ruby Chumber
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Gaurav Vashisht
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Sophie Miller
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Christina O'Dowd
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Thomas Ledson
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Upendram Srinivas-Shankar
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| |
Collapse
|
9
|
Wukich DK, Raspovic KM, Jupiter DC, Heineman N, Ahn J, Johnson MJ, Liu GT, VanPelt MD, Lafontaine J, Lavery L, Kim P, Nakonezny PA. Amputation and infection are the greatest fears in patients with diabetes foot complications. J Diabetes Complications 2022; 36:108222. [PMID: 35717355 DOI: 10.1016/j.jdiacomp.2022.108222] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/30/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022]
Abstract
AIMS To determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications. METHODS 478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy. RESULTS Of the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8-4.5), major LEA (OR 2.8, 95 % CI 1.8-4.4), minor LEA (OR 2.3, 95 % CI 1.5-3.5), blindness (OR 2.0, 95 % CI 1.3-3.2), dialysis (OR 2.0, 95 % CI 1.1-3.3), and death (OR 2.4, 95 % CI 1.4-4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation. CONCLUSION Patients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.
Collapse
Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America.
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Daniel C Jupiter
- Department of Preventive Medicine and Population Health Office of Biostatistics, University of Texas Medical Branch Galveston, TX 77550, United States of America
| | - Nathan Heineman
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Junho Ahn
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Matthew J Johnson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - George T Liu
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Michael D VanPelt
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Javier Lafontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Larry Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Paul Kim
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, United States of America
| | - Paul A Nakonezny
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, United States of America
| |
Collapse
|
10
|
Winkler E, Schöni M, Krähenbühl N, Uçkay I, Waibel FWA. Foot Osteomyelitis Location and Rates of Primary or Secondary Major Amputations in Patients With Diabetes. Foot Ankle Int 2022; 43:957-967. [PMID: 35582923 PMCID: PMC9260474 DOI: 10.1177/10711007221088552] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diabetic foot osteomyelitis (DFO) often leads to amputations in the lower extremity. Data on the influence of the initial anatomical DFO localization on ultimate major amputation are limited. METHODS In this retrospective analysis, 583 amputation episodes in 344 patients (78 females, 266 males) were analyzed. All received a form of amputation in combination with antibiotic therapy. A multivariate logistic regression analysis with the primary outcome "major amputation" defined as an amputation above the ankle joint was performed. The association of risk factors including location of DFO, coronary artery disease, peripheral artery disease, neuropathy, nephropathy, and Charcot neuro-osteoarthropathy was analyzed. RESULTS Among 583 episodes, DFO was located in the forefoot in 512 (87.8%), in the midfoot in 43 (7.4%), and in the hindfoot in 28 episodes (4.8%). Overall, 53 of 63 (84.1%) major amputations were performed because of DFO in the setting of peripheral artery disease as primary indication. Overall, limb loss occurred in 6.1% (31/512) of forefoot, 20.9% (9/43) of midfoot, and 46.4% (13/28) of hindfoot DFO. Among these, 22 (41.5%) were performed as the primary treatment, whereas 31 (58.5%) followed previously failed minor amputations. Among this latter group of secondary major amputations, the DFO was localized to the forefoot in 23 of 583 (3.9%), the midfoot in 4 of 583 (0.7%) and the hindfoot in 4 of 583 (0.7%). In multivariate logistic regression analysis, initial hindfoot localization was a significant factor (P < .05), whereas peripheral artery disease, smoking, and a midfoot DFO were not found to be risk factors. CONCLUSION In our retrospective series, the frequency of limb loss in DFO increased with more proximal initial foot DFO lesions, with almost half of patients losing their limbs with a hindfoot DFO. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
Collapse
Affiliation(s)
- Elin Winkler
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland,Elin Winkler, MD, Department of
Orthopedics, Balgrist University Hospital, Forchstrasse 340, Zürich, 8008,
Switzerland.
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Nicola Krähenbühl
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Ilker Uçkay
- Infectiology, Unit for Clinical and
Applied Research and Infectiology, Balgrist University Hospital, Zurich,
Switzerland
| | - Felix W. A. Waibel
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
11
|
Deldar R, Cach G, Sayyed AA, Truong BN, Kim E, Atves JN, Steinberg JS, Evans KK, Attinger CE. Functional and Patient-reported Outcomes following Transmetatarsal Amputation in High-risk Limb Salvage Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4350. [PMID: 35646494 PMCID: PMC9132523 DOI: 10.1097/gox.0000000000004350] [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: 04/07/2022] [Accepted: 04/12/2022] [Indexed: 11/26/2022]
Abstract
Background Transmetatarsal amputation (TMA) is performed in patients with nonhealing wounds of the forefoot. Compared with below-knee amputations, healing after TMA is less reliable, and often leads to subsequent higher-level amputation. The aim of this study was to evaluate the functional and patient-reported outcomes of TMA. Methods A retrospective review of patients who underwent TMA from 2013 to 2021 at our limb-salvage center was conducted. Primary outcomes included postoperative complications, secondary proximal lower extremity amputation, ambulatory status, and mortality. Univariate and multivariate analyses were performed to evaluate independent risk factors for higher-level amputation after TMA. Patient-reported outcome measures for functionality and pain were also obtained. Results A total of 146 patients were identified. TMA success was achieved in 105 patients (72%), and 41 patients (28%) required higher-level amputation (Lisfranc: 31.7%, Chopart: 22.0%, below-knee amputations: 43.9%). There was a higher incidence of postoperative infection in patients who subsequently required proximal amputation (39.0 versus 9.5%, P < 0.001). At mean follow-up duration of 23.2 months (range, 0.7-97.6 months), limb salvage was achieved in 128 patients (87.7%) and 83% of patients (n = 121) were ambulatory. Patient-reported outcomes for functionality corresponded to a mean maximal function of 58.9%. Pain survey revealed that TMA failure patients had a significantly higher pain rating compared with TMA success patients (P = 0.016). Conclusions TMA healing remains variable, and many patients will eventually require a secondary proximal amputation. Multi-institutional studies are warranted to identify perioperative risk factors for higher-level amputation and to further evaluate patient-reported outcomes.
Collapse
Affiliation(s)
- Romina Deldar
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Gina Cach
- Georgetown University School of Medicine, Washington, D.C
| | - Adaah A. Sayyed
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
- Georgetown University School of Medicine, Washington, D.C
| | | | - Emily Kim
- Georgetown University School of Medicine, Washington, D.C
| | - Jayson N. Atves
- Department of Podiatric Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - John S. Steinberg
- Department of Podiatric Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Karen K. Evans
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Christopher E. Attinger
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| |
Collapse
|
12
|
Fan KL, Bekeny JC, Kennedy CJ, Zolper EG, Steinberg JS, Attinger CE, Evans KK, DeLia D. A Focus on Amputation Level: Factors Preventing Length Preservation in the National Inpatient Sample. J Am Podiatr Med Assoc 2022; 112:20-028. [PMID: 35324459 DOI: 10.7547/20-028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Diabetic lower-extremity disease is the primary driver of mortality in patients with diabetes. Amputations at the forefoot or ankle preserve limb length, increase function, and, ultimately, reduce deconditioning and mortality compared with higher-level amputations, such as below-the-knee amputations (BKAs). We sought to identify risk factors associated with amputation level to understand barriers to length-preserving amputations (LPAs). METHODS Diabetic lower-extremity admissions were extracted from the 2012-2014 National Inpatient Survey using ICD-9-CM diagnosis codes. The main outcome was a two-level variable consisting of LPAs (transmetatarsal, Syme, and Chopart) versus BKAs. Logistic regression analysis was used to determine contributions of patient- and hospital-level factors to likelihood of undergoing LPA versus BKA. RESULTS The study cohort represented 110,355 admissions nationally: 42,375 LPAs and 67,980 BKAs. The population was predominantly white (56.85%), older than 50 years (82.55%), and male (70.38%). On multivariate analysis, living in an urban area (relative risk ratio [RRR] = 1.48; P < .0001) and having vascular intervention in the same hospital stay (RRR = 2.96; P < .0001) were predictive of LPA. Patients from rural locations but treated in urban centers were more likely to receive BKA. Minorities were more likely to present with severe disease, limiting delivery of LPAs. A high Elixhauser comorbidity score was related to BKA receipt. CONCLUSIONS This study identifies delivery biases in amputation level for patients without access to large, urban hospitals. Rural patients seeking care in these centers are more likely to receive higher-level amputations. Further examination is required to determine whether earlier referral to multidisciplinary centers is more effective at reducing BKA rates versus satellite centers in rural localities.
Collapse
Affiliation(s)
- Kenneth L Fan
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jenna C Bekeny
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher J Kennedy
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Elizabeth G Zolper
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - John S Steinberg
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher E Attinger
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Derek DeLia
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC.,†MedStar Health Research Institute, Hyattsville, MD
| |
Collapse
|
13
|
Achieving Functional Outcomes after Surgical Management of Catastrophic Vasopressor-induced Limb Ischemia. Plast Reconstr Surg Glob Open 2022; 10:e4175. [PMID: 35265449 PMCID: PMC8901208 DOI: 10.1097/gox.0000000000004175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/06/2022] [Indexed: 12/02/2022]
Abstract
Vasopressor-induced limb ischemia is an unfortunate complication that can occur in patients treated for septic shock. Current literature lacks surgical treatment recommendations for this condition, besides amputation. We describe various reconstructive surgeries and functional outcomes in patients treated surgically for vasopressor-induced limb ischemia.
Collapse
|
14
|
Solignac J, Bataille S, Touzot M, Bruner F, Bouchouareb D, Brunet P, Ridel C, Robert T. Rheopheresis for severe peripheral arterial disease in hemodialysis patients: A clinical series. J Clin Apher 2021; 37:91-99. [PMID: 34874570 DOI: 10.1002/jca.21955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 11/07/2021] [Accepted: 11/19/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Rheopheresis is a double-filtration plasmapheresis that removes high-molecular-weight molecules from the plasma and thereby lowers blood viscosity. This treatment has been proposed in hemodialysis (HD) patients for chronic limb-threatening ischemia (CLTI), but very few studies have evaluated the usefulness of this technique. PRINCIPAL OBJECTIVE To assess 1-year amputation-free survival (AFS) of HD patients suffering from CLTI treated by rheopheresis. MATERIAL AND METHOD We conducted a retrospective study of 28 consecutive HD patients treated by rheopheresis in three French dialysis centers between 1 February 2017 and 30 April 2019 in two indications resulting from CLTI, namely chronic ulceration or recent minor amputation with delayed healing. RESULTS One-year AFS rate reached 53.6 (-19.8; +16.3)%. One-year overall survival rate reached 67.9 (-20.5; +13.1)%. Main causes of death were infections and related to palliative care implying reduction or withdrawal of regular dialysis treatment. Hypotension episodes were the main rheopheresis adverse events with a prevalence rate of 13.5%. Rheopheresis sessions significantly reduced fibrinogen, C-reactive protein, α2-macroglobulin, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, IgM, and estimated plasma viscosity (P < .0001). CONCLUSION Rheopheresis may improve clinical outcomes of CLTI in HD patients. The assessment of rheopheresis effectiveness needs to be confirmed by a multicenter randomized controlled trial, such as the ongoing project in France (RHEO-PAD, NCT: 03975946).
Collapse
Affiliation(s)
- Justine Solignac
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France.,Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France
| | - Stanislas Bataille
- Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France.,Phocean Nephrology Institute, Clinique Bouchard, ELSAN, Marseille, France
| | - Maxime Touzot
- Centre of Dialysis Association pour utilisation du rein artificiel dans la région parisienne (AURA) Saint Joseph, Hôpital de Paris Saint Joseph, CHU de Paris V, Paris, France
| | - Flora Bruner
- Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France
| | - Dammar Bouchouareb
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Philippe Brunet
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Christophe Ridel
- Centre of Dialysis Association pour utilisation du rein artificiel dans la région parisienne (AURA) Saint Joseph, Hôpital de Paris Saint Joseph, CHU de Paris V, Paris, France
| | - Thomas Robert
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France.,Service de néphrologie et transplantation, APHM, Hôpital de la Conception, Marseille, France
| |
Collapse
|
15
|
Meshkin DH, Zolper EG, Chang K, Bryant M, Bekeny JC, Evans KK, Attinger CE, Fan KL. Long-term Mortality After Nontraumatic Major Lower Extremity Amputation: A Systematic Review and Meta-analysis. J Foot Ankle Surg 2021; 60:567-576. [PMID: 33509714 DOI: 10.1053/j.jfas.2020.06.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/17/2020] [Accepted: 06/23/2020] [Indexed: 02/03/2023]
Abstract
Chronic wounds that lead to major lower extremity amputation have immense consequences on quality of life, and ultimately, mortality. However, mortality rates after lower extremity amputation for a chronic wound are broad within the literature and have escaped precise definition. This systematic review aims to quantify long-term mortality rates after major lower extremity amputation in the chronic wound population available in the existing literature. Ovid MEDLINE was searched for publications which provided mortality data after major, nontraumatic, primary lower extremity amputations. Lower extremity amputations were defined as below and above the knee amputation. Data from included studies was analyzed to obtain pooled 1-, 2-, 3-, 5- and 10-year mortality rates. Sixty-one studies satisfied inclusion criteria representing 36,037 patients who underwent nontraumatic major lower extremity amputation. Pooled mortality rates were 33.7%, 51.5%, 53%, 64.4%, and 80% at 1-, 2-, 3-, 5- and 10-year follow-up, respectively. Within the 8184 diabetic patients (types 1 and 2), 1- and 5-year mortality was 27.3% and 63.2%. Sources of mortality data were varied and included electronic medical records, national health and insurance registries, and government databases. Mortality after nontraumatic major lower extremity amputation is high, both in patients with diabetes as well as those without. Methods used to measure and report mortality are inconsistent, lack reliability, and may underestimate true mortality rates. These findings illustrate the need for a paradigm shift in wound management and improved outcomes reporting. A focus on amputation prevention and care within a multidisciplinary team is critical for recalcitrant ulcers.
Collapse
Affiliation(s)
- Dean H Meshkin
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Elizabeth G Zolper
- Medical Student, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Kevin Chang
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Meigan Bryant
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Jenna C Bekeny
- Medical Student, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Professor of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington
| | - Christopher E Attinger
- Professor of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington
| | - Kenneth L Fan
- Assistant Professor Plastic Surgery, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC.
| |
Collapse
|
16
|
Albright RH, Joseph RM, Wukich DK, Armstrong DG, Fleischer AE. Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective? Clin Orthop Relat Res 2020; 478:2869-2888. [PMID: 32694315 PMCID: PMC7899431 DOI: 10.1097/corr.0000000000001416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/26/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. QUESTIONS/PURPOSES To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. METHODS A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. RESULTS The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. CONCLUSIONS Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. LEVEL OF EVIDENCE Level II, economic and decision analysis.
Collapse
Affiliation(s)
- Rachel H Albright
- R. H. Albright, The Dartmouth Institute, Geisel School of Medicine, Hanover, NH, USA
| | - Robert M Joseph
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Dane K Wukich
- D. K. Wukich, Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - David G Armstrong
- D. G. Armstrong, Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Adam E Fleischer
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- A. E. Fleischer, Weil Foot and Ankle Institute, Mount Prospect, IL, USA
| |
Collapse
|
17
|
Gkotsoulias E. Split Thickness Skin Graft of the Foot and Ankle Bolstered With Negative Pressure Wound Therapy in a Diabetic Population: The Results of a Retrospective Review and Review of the Literature. Foot Ankle Spec 2020; 13:383-391. [PMID: 31370687 PMCID: PMC7493201 DOI: 10.1177/1938640019863267] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Split thickness skin graft (STSG) is a versatile procedure performed for the treatment of wounds resulting from varying pathology. This remains very useful because of its ability for quick healing and low complication rate. The surface of the foot and ankle is an area frequently affected by severe skin and soft tissue structure infections (SSTIs) whose treatment results in wounds. These infections and resultant surgical wounds are commonly seen patients with diabetes. The objective of the present study was to retrospectively evaluate initial healing and immediate post-operative outcomes following STSG application in a diabetic population when negative pressure wound therapy (NPWT) was used as a bolster. Ten patients were identified, including 11 surgical wounds, who underwent STSG bolstered with NPWT from January 2016 to October 2018. Mean follow-up was 13 months (range 1-33 months) with an average time to heal of 17 days (range 14-30 days) for 11 surgical wounds averaging 57 cm2 (range 6.3 - 91 cm2). Consistent improved outcomes have been demonstrated when compared to alternative bolstering techniques available in the literature making a STSG bolstered with NPWT a powerful tool in the reconstruction of diabetic foot wounds resulting from the treatment of infection.Levels of Evidence: Level IV.
Collapse
|
18
|
Körpinar Ş. A Retrospective Analysis of Microbiologic Profile of Foot Infections in Patients With Diabetic End-Stage Renal Disease. INT J LOW EXTR WOUND 2020; 20:15-21. [DOI: 10.1177/1534734620958364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Individuals with diabetes and end-stage renal disease (ESRD) are at increased risk of foot ulceration and lower extremity amputation. Although risk factors and microbiologic analysis of diabetic foot infections ( DFIs) have been extensively studied, there are limited data available for this characteristic group. Methods Clinical, demographic, laboratory, microbiological data, and foot examination information were collected retrospectively regarding 94 patients with ESRD who were referred for DFI between 2006 and 2016 to hyperbaric oxygen therapy. Results In 6 of 94 patients with ESRD (mean age 60 years; 65 males [69.1%], 29 women [30.8%]; 91 undergoing hemodialysis [96.8%], one peritoneal dialysis [1%], two [2%] recent renal transplants), the lesions were bilateral; therefore, the evaluations were made over 100 DFIs. The most common pathogens isolated in deep wound cultures were Staphylococcus aureus and Pseudomonas aeruginosa, respectively, contributing to 27 (21.2%) and 16 (12.5%) of all 127 isolates. When the distribution of the isolates according to different Wagner grades were analyzed, it was found that the proportion of Gramnegative isolates increased statistically significantly with the ascending Wagner grade (P = .004). Conclusion DFIs indicate a serious complication associated with a high risk of amputation, prolonged antibiotic treatment, increased hospital and procedure demands, and the cost of health care, on patients with ESRD. The familiarization of causative pathogens underlying DFIs can aid the clinicians in the choice of appropriate empirical antibiotic treatment. This study emphasizes the need for greater attention to risk factors and the microbiologic profile of DFIs in this characteristic group.
Collapse
|
19
|
Yammine K, Hayek F, Assi C. A meta-analysis of mortality after minor amputation among patients with diabetes and/or peripheral vascular disease. J Vasc Surg 2020; 72:2197-2207. [PMID: 32835790 DOI: 10.1016/j.jvs.2020.07.086] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 07/06/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Foot complications in patients with diabetes or peripheral artery disease (PAD) are serious events in the life of these patients that often lead to amputations and mortality. No evidence synthesis has been reported on the mortality rates after minor lower extremity amputation; thus, a quantitative evidence synthesis was needed. METHODS A systematic literature search was performed to identify studies that had reported the survival or mortality rates after a minor LEA. The studies were required to include one or more of the following primary outcomes: mortality rate at 30 days, 1 year, 3 years, 5 years, 6 to 7 years, or 8 to 9 years. The secondary outcomes were the mortality rates according to the anatomic location of the amputation in the foot and the independent risk factors for mortality. RESULTS A total of 28 studies with 17,325 subjects fulfilled the inclusion criteria. The meta-analytical results of the mortality rates were as follows: 3.5% at 1 month, 20% at 1 year, 28% at 3 years, 44.1% at 5 years, 51.3% at 6 to 7 years, and 58.5% at 8 to 9 years. From these studies of diabetic patients, age was the most consistent independent risk factor, followed by chronic kidney disease, PAD, and coronary artery disease. One study of patients with PAD had reported diabetes as an independent risk factor for mortality. The subgroup analysis of the four studies reporting the outcomes of patients with PAD showed greater 3- and 5-year mortality rates compared with the overall and "diabetic" results. CONCLUSIONS Mortality after minor amputation for patients with diabetes and/or PAD was found to be very high. Compared with the reported cancer data, survival was worse than that for many cancers. Just as in the case of major amputations, minor amputations should be considered a pivotal event in the life of these patients.
Collapse
Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon; Division of Vascular Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon.
| | - Fady Hayek
- Division of Vascular Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon; Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
| |
Collapse
|
20
|
Okoro T, Sikirica V, Casillas L, Brion T, Devine J, Ong V, Howard K. Elicitation of disease concepts in patients with diabetic foot ulcers: a qualitative study. J Wound Care 2020; 29:S38-S45. [PMID: 32412892 DOI: 10.12968/jowc.2020.29.sup5a.s38] [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: 11/11/2022]
Abstract
OBJECTIVE To identify in-depth information directly from patients with diabetic foot ulcers (DFU) on DFU symptoms, impacts on functioning and effects on health-related quality of life (HRQoL). METHOD Semi-structured, qualitative concept elicitation interviews were conducted with patients with DFUs (Wagner grade 1 or 2) until saturation was reached. Qualitative analysis (using MAXQDA, VERBI GmbH, Germany) of interview transcripts was conducted to identify concepts relevant to patients with DFUs, based on the frequency of mentions, and elucidate themes regarding impacts on HRQoL. RESULTS Of the 18 participants, most were male (n=14; 78%) and 10 (56%) presented with a Wagner grade of 1. Frequently reported symptoms were pain/discomfort (n=15; 83%), weeping/discharge (n=10; 56%), bleeding (n=10; 56%) and swelling (n=8; 44%). Overall, patients reported more impacts than symptoms-wound care/treatment burden (n=14; 78%), limitations on exercise/physical activity (n=13; 72%), mobility limitations (n=12; 67%), and offloading (n=12; 67%) were the most frequently mentioned. Based on findings from the patient interviews, a draft conceptual model was developed outlining interrelationships between DFU symptoms, impacts, and HRQoL from the patient perspective. CONCLUSION Qualitative interviews captured the breadth of disease-related concepts of direct importance to patients. The draft conceptual model developed from the analysis can help identify measures or instruments for use in assessing patient-reported symptoms or HRQoL in clinical practice and may have wider research applicability, including evaluation of treatment benefits in patients with DFUs.
Collapse
Affiliation(s)
| | | | | | - Triza Brion
- ICON Clinical Research, South San Francisco, CA, US
| | - Jacob Devine
- ICON Clinical Research, South San Francisco, CA, US
| | - Vivien Ong
- ICON Clinical Research, South San Francisco, CA, US
| | | |
Collapse
|
21
|
Schroijen MA, van Diepen M, Hamming JF, Dekker FW, Dekkers OM. Mortality after amputation in dialysis patients is high but not modified by diabetes status. Clin Kidney J 2019; 13:1077-1082. [PMID: 33391752 PMCID: PMC7769538 DOI: 10.1093/ckj/sfz116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/07/2019] [Indexed: 01/22/2023] Open
Abstract
Background Survival among dialysis patients with diabetes mellitus (DM) is inferior to survival of non-diabetic dialysis patients, probably due to the higher prevalence of diabetes-related comorbid conditions. One could hypothesize that these comorbid conditions also contribute to a decreased survival after amputation in diabetic patients compared with non-diabetic patients on dialysis. Methods Data were collected from the Netherlands Cooperative Study on the Adequacy of Dialysis, a multicentre, prospective cohort study in which new patients with end-stage renal disease were monitored until transplantation or death. Amputation rates (incident cases) were calculated in patients with and without DM. The primary endpoint was all-cause survival after first amputation during dialysis therapy in diabetic patients compared with non-diabetic dialysis patients with an amputation. This was formally assessed using interaction analysis (Poisson regression). Results During follow-up (mean duration 2.9 years), 50 of the 413 diabetic patients had a new amputation (12.1%), compared with 20 of 1553 non-diabetic patients (1.2%). Amputation rates/1000 person-years were 47.9 [95% confidence interval (CI) 36.3–63.2] and 4.1 (95% CI 2.7–6.4), respectively, for diabetic patients and non-diabetic patients. Amputation increased mortality risk more than 4-fold in patients without diabetes [hazard ratio (HR) 4.6 (95% CI 2.8–7.6)] as well as in patients with diabetes [HR 4.6 (95% CI 3.3–6.4)]. No formal interaction between diabetes and amputation was found (P = 0.12). Conclusions Amputation in dialysis patients is associated with a 4-fold increased mortality risk; this mortality risk was similar for diabetes and non-diabetes patients. Importantly, the risk for amputation is 10-fold higher in DM compared with non-diabetic dialysis patients.
Collapse
Affiliation(s)
- Marielle A Schroijen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jaap F Hamming
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
22
|
Davis KE, La Fontaine J, Farrar D, Oz OK, Crisologo PA, Berriman S, Lavery LA. Randomized clinical study to compare negative pressure wound therapy with simultaneous saline irrigation and traditional negative pressure wound therapy for complex foot infections. Wound Repair Regen 2019; 28:97-104. [PMID: 31245901 PMCID: PMC6973291 DOI: 10.1111/wrr.12741] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/03/2019] [Indexed: 11/28/2022]
Abstract
The aim of this study was to compare the efficacy of different negative pressure wound therapy (NPWT) devices and NPWT with and without simultaneous irrigation in patients admitted to hospital with moderate and severe foot infections. Ninety patients were randomized in a 12‐week prospective, randomized noninferiority trial to compare wound healing in patients with moderate and severe infected foot wounds treated with NPWT after surgery. Inclusion criteria included ABI > 0.5 or toe pressures >30 PVR/mmHg, >18 years of age and exclusion included active Charcot arthropathy, collagen vascular disease, HIV, and hypercoagulable state. We compared two different traditional devices, NPWT‐K (KCI, VAC Ulta) and NPWT‐C (Cardinal, PRO), and NPWT‐I with saline irrigation (Cardinal, PRO). All patients had therapy delivered at 125 mmHg continuous pressure. In patients who received simultaneous saline irrigation (NPWT‐I), the administration rate was 15 ml per hour. The primary outcome was the proportion of healed wounds in 12 weeks. Secondary outcomes included surgical wound closure, number of surgeries, length of stay, and time to wound healing. Continuous data was presented as mean ± standard deviation. Analysis of variance was used to compare continuous variables and chi‐square to compare dichotomous variables with an alpha of 0.05. There were no differences in outcomes among NPWT‐I, NPWT‐C, and NPWT‐K groups in proportion of healed wounds (63.3%, 50.0%, 46.7% p = 0.39), surgical wound closure (83.3%, 80.0%, 63.3%, p = 0.15), number of surgeries (2.0 ± 0.49, 2.4 ± 0.77, 2.4 ± 0.68, p = 0.06), length of stay (16.3 ± 15.7, 14.7 ± 7.4, 15.3 ± 10.5 days, p = 0.87), time to wound healing (46.2 ± 22.8, 40.9 ± 18.8, 45.9 ± 28.3 days, p = 0.78). We did not identify any significant differences in clinical outcomes or adverse events between patients treated with different NPWT devices or NPWT with and without irrigation.
Collapse
Affiliation(s)
- Kathryn E Davis
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David Farrar
- Department of Immunology and Molecular Biology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Orhan K Oz
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Peter A Crisologo
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
23
|
Butler CR, Schwarze ML, Katz R, Hailpern SM, Kreuter W, Hall YN, Montez Rath ME, O'Hare AM. Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD. J Am Soc Nephrol 2019; 30:481-491. [PMID: 30782596 PMCID: PMC6405144 DOI: 10.1681/asn.2018101002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/10/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation. METHODS We conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD. RESULTS Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to-and to have had prolonged stays in-acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services. CONCLUSIONS Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.
Collapse
Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington;
| | - Margaret L Schwarze
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, University of Wisconsin, Madison, Wisconsin
| | - Ronit Katz
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Susan M Hailpern
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - William Kreuter
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Yoshio N Hall
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Maria E Montez Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
- Department of Medicine, Stanford University, Stanford, California; and
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
- Division of Nephrology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| |
Collapse
|
24
|
Biological Mechanisms of Chronic Wound and Diabetic Foot Healing: The Role of Collagen. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2018-0077] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Abstract
The treatment of chronic wounds is a continuously developing research focus. The problems of excessive mechanical forces, infection, inflammation, reduced production of growth factors, and lack of collagen will affect the results of treatment. The purpose of this study was to analysse the elements that lead to long-term non-healing of chronic wounds and trophic ulcers, including diabetic foot syndrome, by determining the optimal treatment algorithm. The paper presents an analysis of the world literature on the etiopathogenesis and principles of chronic wound treatment in diabetic foot syndrome. The epidemiology of chronic wounds of different genesis is presented. The issues of physiological and metabolic disorders in chronic ulcers affecting the process of wound healing are discussed. Particular attention is paid to collagen, which is a protein that forms the basis of connective tissue; collagen ensures the strength and elasticity of the skin, which confirms the importance of its role not only in aesthetics but also in the process of wound healing. Different types of collagen and their roles in the mechanisms of chronic wound healing in diabetic foot syndrome are described. The results of clinical studies evaluating the effectiveness of medical products and preparations, consisting of collagen with preserved (native collagen) and fractionated structures, in treating chronic wounds of diabetic foot syndrome are analysed. It has been shown that the use of native collagen preparations is a promising treatment for chronic ulcers and wounds, including diabetic foot syndrome, which makes it possible to increase the effectiveness of treatment and reduce the economic costs of managing these patients.
Collapse
|
25
|
Ciufo DJ, Thirukumaran CP, Marchese R, Oh I. Risk factors for reoperation, readmission, and early complications after below knee amputation. Injury 2019; 50:462-466. [PMID: 30396770 DOI: 10.1016/j.injury.2018.10.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/16/2018] [Accepted: 10/27/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Many patients undergoing below knee amputations (BKA) return for subsequent unplanned operations, hospital readmission, or postoperative complications. This unplanned medical management negatively impacts both patient outcomes and our healthcare system. This study primarily investigates the risk factors for unplanned reoperation following BKA. METHODS Below knee amputations from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from the years 2012-2014 were identified by CPT code 27880 for amputation through the tibia and fibula. Our query identified 4631 BKA cases, including 30 day complications. Multivariate logistic regression modeling was performed on several patient demographic and disease factors to assess for independent predictors of unplanned reoperation. Secondary outcomes of unplanned and related readmissions (related to the procedure), major complications, minor complications, and mortality were also included in the analysis. RESULTS Of 4631 BKAs identified, 9.63% (446/4631) underwent unplanned reoperations and 8.75% (405/4631) had unplanned and related readmissions. Major complications were experienced by 12.8% (593/4631) and minor complications by 8.7% (401/4631). Thirty day mortality rate was 5.14% (238/4631). The most common procedures for unplanned operations were thigh amputations (128/446, 28.7%), debridement/secondary closure (114/446, 25.6%), and revision leg amputations (46/446, 10.32%). Factors associated with an increased risk of unplanned reoperation included patients transferred from another facility (Adjusted Odds Ratio [AOR] = 1.28; p = .04), recent smokers (AOR = 1.34; p = .02), bleeding disorder (AOR = 1.30; p = .02), and preoperative ventilator use (AOR = 2.38; p = .01). CONCLUSION Patients that were ongoing/recent smokers, had diagnosed bleeding disorders, required preoperative ventilator use, or were transferred in from another facility were associated with the highest risks of reoperation following BKA. This patient population experiences high rates of reoperation, readmission, complication, and mortality.
Collapse
Affiliation(s)
- David J Ciufo
- University of Rochester, Department of Orthopaedics and Rehabilitation, United States.
| | | | | | - Irvin Oh
- University of Rochester, Department of Orthopaedics and Rehabilitation, United States
| |
Collapse
|
26
|
Xie P, Young MW, Bian H, Niknam-Bienia S, Hong S, Mustoe TA, Galiano RD. Renal dysfunction aggravated impaired cutaneous wound healing in diabetic mice. Wound Repair Regen 2018; 27:49-58. [DOI: 10.1111/wrr.12682] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 10/12/2018] [Accepted: 10/21/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Ping Xie
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois
| | - Mimi Wu Young
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois
| | - Huining Bian
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois
| | - Solmaz Niknam-Bienia
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois
| | - Seok Hong
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois
| | - Thomas A Mustoe
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois
| | - Robert D Galiano
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois
| |
Collapse
|
27
|
Del Core MA, Ahn J, Lewis RB, Raspovic KM, Lalli TAJ, Wukich DK. The Evaluation and Treatment of Diabetic Foot Ulcers and Diabetic Foot Infections. FOOT & ANKLE ORTHOPAEDICS 2018. [DOI: 10.1177/2473011418788864] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Diabetic foot ulcers and infections are common complications of diabetic foot disease. Additionally, these complications are a common cause of morbidity and impose a substantial burden to the patient and society. It is imperative to understand the major contributing factors, namely, diabetic neuropathy, peripheral arterial disease, and immune system dysfunction in order to guide treatment. Management of diabetic foot disease begins with a detailed history and thorough physical examination. This examination should focus on the manifestations of diabetic neuropathy and peripheral arterial disease, and, in particular, any evidence of diabetic foot ulcers or infection. Prevention strategies should include a multi-disciplinary approach centered on patient education.
Collapse
Affiliation(s)
- Michael A. Del Core
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Junho Ahn
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Robert B. Lewis
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Katherine M. Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Trapper A. J. Lalli
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Dane K. Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
28
|
Del Core MA, Ahn J, Wukich DK, Liu GT, Lalli T, VanPelt MD, Raspovic KM. Gender Differences on SF-36 Patient-Reported Outcomes of Diabetic Foot Disease. INT J LOW EXTR WOUND 2018; 17:87-93. [PMID: 29929411 DOI: 10.1177/1534734618774664] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The primary aim of this study was to evaluate the impact of gender on health-related quality of life (HRQOL) using a generic (Short Form-36 [SF-36]) and region-specific (Foot and Ankle Ability Measure [FAAM]) health measurement tool among a matched cohort of male and female patients with diabetes-related foot complications. The HRQOL of 240 patients with diabetic foot disease was measured using the SF-36 and the FAAM surveys. A total of 120 male patients were matched with 120 female patients with the same primary diagnosis, age, type, and duration of diabetes and insulin use. The SF-36 physical component summary (PCS) and mental component summary (MCS) scores were calculated using orthogonal and oblique rotation methods. The median age of the respondents was 54 years (interquartile range = 46-61). No differences in patient characteristics were found between genders. Among the SF-36 subscales, women reported significantly worse physical function ( P = .014) and bodily pain ( P = .021) scores with a trending decrease in general health score ( P = .067). Subsequently, women had worse orthogonal ( P = .009) and oblique PCS scores ( P = .036) than men. However, orthogonal ( P = .427) or oblique ( P = .140) MCS scores did not differ between groups. No significant differences in FAAM scores with respect to gender were appreciated. Our findings suggest that in patients with diabetic foot disease, women tend to report lower physical HRQOL compared with men. In efforts to increase compliance, providers should recognize the impact of gender on patients' perceptions of foot-related complications of diabetes. This knowledge may improve outcomes by adapting more individualized and gender-specific approaches to patients.
Collapse
Affiliation(s)
| | - Junho Ahn
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dane K Wukich
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - George T Liu
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Trapper Lalli
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | |
Collapse
|
29
|
Kim YK, Lee HS, Ryu JJ, In Lee H, Seo SG. Sarcopenia increases the risk for mortality in patients who undergo amputation for diabetic foot. J Foot Ankle Res 2018; 11:32. [PMID: 29946364 PMCID: PMC6006937 DOI: 10.1186/s13047-018-0274-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/05/2018] [Indexed: 12/25/2022] Open
Abstract
Background Although there have been reports that diabetes affects the prevalence of sarcopenia, no studies have examined the relationship between sarcopenia and mortality in patients undergoing leg amputation. The purpose of this study is to determine whether sarcopenia affects the mortality rate of patients undergoing diabetic foot amputation. Methods From among patients who underwent limb amputation for diabetes complications, this study included 167 patients who underwent abdominal CT within 1 year of amputation. We defined sarcopenia using sex-specific cut-off points for the L3 skeletal muscle index. The 5-year survival rate was analyzed. All patients were divided into two groups and compared according to the presence of sarcopenia. The mortality rate according to sarcopenia was assessed via the Kaplan-Meier method and log-rank test. Uni- and multivariate Cox regression analyses evaluated factors associated with survival rate. Results Among the total of 167 patients, the overall 5-year mortality rate was 52.7%. Of the 112 patients with sarcopenia, the 5-year mortality rate was 60.7%. Of the 55 patients without sarcopenia, the 5-year mortality rate was 36.4%. Kaplan-Meier analysis showed a high mortality of the sarcopenia group in the univariate (p = 0.016) and multivariate (p = 0.047) analysis. Conclusions Our study is the first to analyze the relationship between diabetic amputation and sarcopenia. Sarcopenia increases the risk of mortality in patients who undergo amputation for diabetic foot. Therefore, patients with diabetes should be careful to prevent sarcopenia with enough regular exercise as well as prevent diabetic foot disease.
Collapse
Affiliation(s)
- You Keun Kim
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Ho Seong Lee
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Jae Jung Ryu
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Hye In Lee
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Sang Gyo Seo
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea.,2Diabetes Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
30
|
Albright V, Xu M, Palanisamy A, Cheng J, Stack M, Zhang B, Jayaraman A, Sukhishvili SA, Wang H. Micelle-Coated, Hierarchically Structured Nanofibers with Dual-Release Capability for Accelerated Wound Healing and Infection Control. Adv Healthc Mater 2018; 7:e1800132. [PMID: 29683273 PMCID: PMC6347427 DOI: 10.1002/adhm.201800132] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 03/03/2018] [Indexed: 12/18/2022]
Abstract
Tailoring nanofibrous matrices-a material with much promise for wound healing applications-to simultaneously mitigate bacterial colonization and stimulate wound closure of infected wounds is highly desirable. To that end, a dual-releasing, multiscale system of biodegradable electrospun nanofibers coated with biocompatible micellar nanocarriers is reported. For wound healing, transforming growth factor-β1 is incorporated into polycaprolactone/collagen (PCL/Coll) nanofibers via electrospinning and the myofibroblastic differentiation of human dermal fibroblasts is locally stimulated. To prevent infection, biocompatible nanocarriers of polypeptide-based block copolymer micelles are deposited onto the surfaces of PCL/Coll nanofibers using tannic acid as a binding partner. Micelle-modified fibrous scaffolds are favorable for wound healing, not only supporting the attachment and spreading of fibroblasts comparable to those on noncoated nanofibers, but also significantly enhancing fibroblast migration. Micellar coatings can be loaded with gentamicin or clindamycin and exhibit antibacterial activity as measured by Petrifilm and zone of inhibition assays as well as time-dependent reduction of cellular counts of Staphylococcus aureus cultures. Moreover, delivery time of antibiotic dosage is tunable through the application of a novel modular approach. Altogether, this system holds great promise as an infection-mitigating, cell-stimulating, biodegradable skin graft for wound management and tissue engineering.
Collapse
Affiliation(s)
- Victoria Albright
- Department of Materials Science and Engineering, Texas A&M University, 575 Ross Street, College Station, TX 77843, USA
| | - Meng Xu
- Department of Chemistry and Chemical Biology, Stevens Institute of Technology, 1 Castle Point on the Hudson, Hoboken, NJ 07030, USA
| | - Anbazhagan Palanisamy
- Department of Materials Science and Engineering, Texas A&M University, 575 Ross Street, College Station, TX 77843, USA
| | - Jun Cheng
- Department of Chemistry and Chemical Biology, Stevens Institute of Technology, 1 Castle Point on the Hudson, Hoboken, NJ 07030, USA
| | - Mary Stack
- Department of Biomedical Engineering, Stevens Institute of Technology, 1 Castle Point on the Hudson, Hoboken, NJ 07030, USA
| | - Beilu Zhang
- Department of Chemistry and Chemical Biology, Stevens Institute of Technology, 1 Castle Point on the Hudson, Hoboken, NJ 07030, USA
| | - Arul Jayaraman
- Department of Chemical Engineering, Department of Biomedical Engineering, Texas A&M University
| | - Svetlana A. Sukhishvili
- Department of Materials Science and Engineering, Texas A&M University, 575 Ross Street, College Station, TX 77843, USA,
| | - Hongjun Wang
- Department of Chemistry and Chemical Biology, Stevens Institute of Technology, 1 Castle Point on the Hudson, Hoboken, NJ 07030, USA,
| |
Collapse
|
31
|
Wukich DK, Raspovic KM. Assessing Health-Related Quality of Life in Patients With Diabetic Foot Disease: Why Is It Important and How Can We Improve? The 2017 Roger E. Pecoraro Award Lecture. Diabetes Care 2018; 41:391-397. [PMID: 29463665 DOI: 10.2337/dci17-0029] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patient-reported outcomes (PROs) have become an important subject in the area of diabetes-related foot complications. Self-reported health-related quality of life (HRQOL) surveys can provide a generic measure of overall health (global) and can be disease specific (i.e., diabetes) or even region specific (i.e., lower-extremity function). Analysis of PRO measures utilizing validated instruments allows health care providers to determine whether medical and surgical treatments are providing patients with the highest level of outcome possible and are actually improving HRQOL. The 36-item Short Form (SF-36), EuroQol five-dimension questionnaire (EQ-5D-5L), and Foot and Ankle Ability Measure (FAAM) are examples of commonly used HRQOL surveys. Low HRQOL has been associated with higher rates of hospital admission and mortality in patients with diabetes. Previous studies have demonstrated that patients with diabetes-related foot disease have low self-reported physical quality of life but do not typically report low mental quality of life. The impact of mental quality of life may be underestimated in these patients using the SF-36. In this article, we will discuss several widely used outcome instruments used to measure patient HRQOL and the impact of diabetic foot disease on HRQOL. As health care providers, we must continue to adjust and modify our treatments to achieve the best patient outcomes and associated high quality of life. Assessing PROs will become increasingly important as health care systems transition from a volume-based reimbursement model to a value-based model.
Collapse
Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
32
|
Raspovic KM, Ahn J, La Fontaine J, Lavery LA, Wukich DK. End-Stage Renal Disease Negatively Affects Physical Quality of Life in Patients With Diabetic Foot Complications. INT J LOW EXTR WOUND 2017; 16:135-142. [PMID: 28682731 DOI: 10.1177/1534734617707081] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The aim of this study was to evaluate the impact of end-stage renal disease (ESRD) on health-related quality of life (QOL) in patients with diabetic foot disease. We compared a group of 30 diabetic patients with ESRD requiring dialysis to a group of 60 diabetic patients without ESRD. Both groups consisted of patients with active diabetic foot disease (ulcer, Charcot, infection) and were matched with regard to age and gender. Self-reported QOL was assessed using the Short Form-36 (SF-36) physical and mental component summary (PCS and MCS) scores and the region-specific Foot and Ankle Ability Measure (FAAM). Diabetic foot patients with ESRD requiring dialysis were found to have significantly higher creatinine levels, lower hemoglobin levels, lower albumin levels, higher rates of peripheral arterial disease, and lower rates of Charcot neuroarthropathy than patients without ESRD. The median PCS was significantly lower in the ESRD group; however, no significant difference was found when comparing the median MCS and FAAM. Patients who ultimately died had a tendency to report lower PCS scores at baseline compared with those patients who did not die ( P = .07). Patients who ultimately required major amputation also reported lower PCS scores at baseline. ESRD negatively affects physical QOL to a greater degree than mental QOL in patients with diabetic foot disease. The SF-36 may not be sensitive enough to capture impaired mental QOL because both groups had relatively high MCS scores. Low physical QOL may be associated with mortality and the eventual need for major amputation.
Collapse
Affiliation(s)
| | - Junho Ahn
- 2 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Larry A Lavery
- 2 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dane K Wukich
- 2 University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|