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Roberts RHR, Davies-Jones GR, Brock J, Satheesh V, Robertson GAJ. Surgical management of the diabetic foot: The current evidence. World J Orthop 2024; 15:404-417. [PMID: 38835689 PMCID: PMC11145970 DOI: 10.5312/wjo.v15.i5.404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/12/2024] [Accepted: 04/24/2024] [Indexed: 05/15/2024] Open
Abstract
The prevalence of diabetes mellitus and its associated complications, particularly diabetic foot pathologies, poses significant healthcare challenges and economic burdens globally. This review synthesises current evidence on the surgical management of the diabetic foot, focusing on the interplay between neuropathy, ischemia, and infection that commonly culminates in ulcers, infections, and, in severe cases, amputations. The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies, as diabetic foot complications are a leading cause of hospital admissions among diabetic patients, significantly impacting morbidity and mortality rates. This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers, infections, and skeletal pathologies such as Charcot arthropathy, emphasising the critical role of early diagnosis, comprehensive management strategies, and interdisciplinary care in mitigating adverse outcomes. In addressing surgical interventions, this review evaluates conservative surgeries, amputations, and reconstructive procedures, highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies. The integration of advanced diagnostic tools, novel surgical techniques, and postoperative care, including offloading and infection control, are discussed in the context of optimising healing and preserving limb function.
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Affiliation(s)
| | - Gareth Rhys Davies-Jones
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
| | - James Brock
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
| | - Vaishnav Satheesh
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
| | - Greg AJ Robertson
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
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Liew H, Tang W, Plassmann P, Machin G, Simpson R, Edmonds ME, Petrova NL. Infrared Thermography Shows That a Temperature Difference of 2.2°C (4°F) or Greater Between Corresponding Sites of Neuropathic Feet Does Not Always Lead to a Diabetic Foot Ulcer. J Diabetes Sci Technol 2024:19322968241249970. [PMID: 38708580 DOI: 10.1177/19322968241249970] [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] [Indexed: 05/07/2024]
Abstract
BACKGROUND There is emerging interest in the application of foot temperature monitoring as means of diabetic foot ulcer (DFU) prevention. However, the variability in temperature readings of neuropathic feet remains unknown. The aim of this study was to analyze the long-term consistency of foot thermograms of diabetic feet at the risk of DFU. METHODS A post-hoc analysis of thermal images of 15 participants who remained ulcer-free during a 12-month follow-up were unblinded at the end of the trial. Skin foot temperatures of 12 plantar, 15 dorsal, 3 lateral, and 3 medial regions of interests (ROIs) were derived on monthly thermograms. The temperature differences (∆Ts) of corresponding ROIs of both feet were calculated. RESULTS Over the 12-month study period, out of the total 2026 plantar data points, 20.3% ROIs were rated as abnormal (absolute ∆T ≥ 2.2°C). There was a significant between-visit variability in the proportion of plantar ROIs with ∆T ≥ 2.2°C (range 7.6%-30.8%, chi-square test, P = .001). The proportion of patients presenting with hotspots (ROIs with ∆T ≥ 2.2°C), abnormal plantar foot temperature (mean ∆T of 12 plantar ROIs ≥ 2.2°C), and abnormal whole foot temperature (mean ∆T of 33 ROIs ≥ 2.2°C) varied between visits and showed no pattern (P > .05 for all comparisons). This variability was not related to the season of assessment. CONCLUSIONS Despite the high rate of hotspots on monthly thermograms, all feet remained intact. This study underscores a significant between-visit inconsistency in thermal images of neuropathic feet which should be considered when planning DFU-prevention programs for self-testing and behavior modification.
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Affiliation(s)
- Huiling Liew
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
| | - Wegin Tang
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Graham Machin
- Temperature and Humidity Group, National Physical Laboratory, London, UK
| | - Robert Simpson
- Temperature and Humidity Group, National Physical Laboratory, London, UK
| | - Michael E Edmonds
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
- Diabetes and Obesity, School of Cardiovascular and Metabolic Medicine & Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Nina L Petrova
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
- Diabetes and Obesity, School of Cardiovascular and Metabolic Medicine & Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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3
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Carro GV, Guerbi X, Berra M, Rodriguez MG, Noli ML, Fuentes M, Ticona MA, Michelini F, Berra A. Homogenized and Lyophilized Amniotic Membrane Dressings for the Treatment of Diabetic Foot Ulcers in Ambulatory Patients. Foot Ankle Int 2024:10711007241243373. [PMID: 38676564 DOI: 10.1177/10711007241243373] [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] [Indexed: 04/29/2024]
Abstract
BACKGROUND Diabetic foot ulcers (DFUs) constitute a complication that occurs in 19% to 34% of patients with diabetes mellitus (DM). The aim of this study is to describe median days to healing, average velocity of wound closure, and percentage of wound surface closed at 3, 6, and 12 weeks through the use of homogenized and lyophilized amniotic membrane (hAMpe) dressings for the treatment of DFUs in ambulatory patients. METHODS An observational, descriptive, longitudinal study was performed. Patients presenting with granulation-based DFU, after proper debridement, were included from August 19, 2021, until July 14, 2023. hAMpe dressings placed every 3 days were used for the treatment of these ulcers. RESULTS Sixteen patients were included with a mean age of 52.38 (8.07) years. The analyzed lesions were postsurgical ulcers in 15 of the 16 included patients. Median ulcer size was 19.5 cm2 (6.12-36). The median ABI was 1.10 (1-1.14). The median days to healing was 96 (71-170). The median percentage closure of the wound at 3 weeks was 41% (28.9%-55.3%), at 6 weeks it was 68.2% (48.6%-74.2%), and at 12 weeks it was 100% (81%-100%). The average velocity closure was 1.04% per day (95% CI 0.71%-1.31%). It was higher during the closure of the first 50% of the ulcer, 2.12% per day (95% CI 0.16%-4.09%), and decreased from 50% to 25% of the ulcer size to 0.67% per day (95% CI 0.23%-1.10%) and from 25% to closure to 0.47% per day (95% CI 0.14%-0.80%), P < .001. CONCLUSION These results are difficult to compare to other studies given the higher surface area of the ulcers included in our sample. The development of hAMpe dressings enables patients to apply them without requiring assistance from health care teams and was not associated with any recognized complications. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Gabriela Verónica Carro
- Diabetic Foot Unit, Hospital Nacional Profesor Alejandro Posadas, El Paloma, Buenos Aires, Argentina
| | - Ximena Guerbi
- Universidad Nacional de La Plata, La Plata, Buenos Aires, Argentina
| | | | - María Gabriela Rodriguez
- Diabetic Foot Unit, Hospital Nacional Profesor Alejandro Posadas, El Paloma, Buenos Aires, Argentina
| | - María Laura Noli
- Diabetic Foot Unit, Hospital Nacional Profesor Alejandro Posadas, El Paloma, Buenos Aires, Argentina
| | - Mariana Fuentes
- Diabetic Foot Unit, Hospital Nacional Profesor Alejandro Posadas, El Paloma, Buenos Aires, Argentina
| | - Miguel Angel Ticona
- Diabetic Foot Unit, Hospital Nacional Profesor Alejandro Posadas, El Paloma, Buenos Aires, Argentina
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Meloni M, Piaggesi A, Uccioli L. From a Spark to a Flame: The Evolution of Diabetic Foot Disease in the Last Two Decades. INT J LOW EXTR WOUND 2024:15347346241238480. [PMID: 38470358 DOI: 10.1177/15347346241238480] [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: 03/13/2024]
Abstract
Despite many improvements have been achieved, diabetic foot disease (DFD) remains a clinical, social, and economic burden. In the last years, DFD showed an evolution of its characteristics with an increase of the ischaemic/neuro-ischaemic foot in comparison to the pure neuropathic foot. Simultaneously, there was and increased incidence of concomitant cardiovascular co-morbidities, which influences the higher fragility of patients with DFS. Peripheral arterial disease (PAD) in subjects with diabetic foot seems to show a more aggressive pattern, being more distal and difficult to treat. Untreatable PAD remains the unmet need for clinicians and the main risk factor of major amputation in patients with diabetic foot ulcers. Authors aimed to describe the evolution of diabetic foot patients in the last two decades, describing also the current and future treatment which may improve outcomes in the next generations.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Alberto Piaggesi
- Diabetic Foot Section, Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy
| | - Luigi Uccioli
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
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Hon K, Nobels F, Senneville É, Uckay I, Maas M, Fitridge R. Assessment and management of diabetes-related foot infection according to the new International Working Group on the Diabetic Foot guidelines 2023-Multidisciplinary grand rounds. Diabetes Metab Res Rev 2024; 40:e3737. [PMID: 37855302 DOI: 10.1002/dmrr.3737] [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: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
Diabetes-related foot disease is a serious and common complication for people with diabetes mellitus. The gold standard care for a person with diabetes-related foot disease is the involvement of a multidisciplinary foot team engaged in evidence-based care. To date, there are seven International Working Group on the Diabetic Foot (IWGDF) guidelines published to assist healthcare providers in managing diabetes-related foot disease around the world. This review discusses the acute management of diabetes-related foot infection with insights from experts of various specialities (internal medicine, infectious disease, vascular surgery, radiology) with a discussion on the implementation of IWGDF guidelines in real life practice and the challenges that healthcare providers may face.
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Affiliation(s)
- Kay Hon
- Discipline of Surgical Specialties, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Frank Nobels
- Department of Internal Medicine-Endocrinology, Onze-Lieve-Vrouw Ziekenhuis Aalst, Aalst, Belgium
| | - Éric Senneville
- Infectious Diseases Department, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Ilker Uckay
- Balgrist University Hospital, Zurich, Switzerland
| | - Mario Maas
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (AUMC), Amsterdam, the Netherlands
| | - Robert Fitridge
- Discipline of Surgical Specialties, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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Alkhalfan Y, Lewis TL, Kavarthapu V, Hester T. Investigation and management of diabetic foot osteomyelitis: An update for the foot and ankle orthopaedic surgeon. J Clin Orthop Trauma 2024; 48:102330. [PMID: 38274641 PMCID: PMC10806189 DOI: 10.1016/j.jcot.2023.102330] [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: 09/28/2023] [Revised: 12/13/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024] Open
Abstract
Diabetic foot osteomyelitis (DFO) poses a significant challenge in the management of diabetic patients, often leading to severe complications and increased morbidity. Effective management of DFO requires a multidisciplinary approach, involving endocrinologists, infectious disease specialists, vascular surgeons, orthopaedic surgeons, and wound care experts. Early diagnosis is paramount, facilitated by advanced imaging techniques such as magnetic resonance imaging (MRI) and bone scintigraphy. Once diagnosed, the treatment strategy hinges on a combination of medical and surgical interventions. Antibiotic therapy, guided by culture results, plays a central role in managing DFO. Tailored regimens targeting the specific pathogens involved are administered, often for prolonged durations. Surgical intervention becomes necessary when conservative measures fall short. Surgical approaches range from minimally invasive procedures, like percutaneous drainage, to more extensive interventions like debridement and bone resection. Prevention of DFO recurrence is equally vital, emphasising glycemic control, meticulous foot care, patient education, monitoring of at-risk signs, revascularization and early intervention when indicated. The management of diabetic foot osteomyelitis mandates a comprehensive strategy that addresses both the infectious and surgical aspects of the condition. A collaborative, interdisciplinary approach ensures timely diagnosis, tailored treatment, and holistic care. Further research into novel therapeutic modalities and long-term outcomes remains essential in refining the management of this complex and debilitating complication of diabetes.
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Affiliation(s)
- Yousif Alkhalfan
- Guy's and St Thomas' NHS Foundation Trust, Maze Pond, London, SE1 9RT, UK
| | | | - Venu Kavarthapu
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, UK
| | - Thomas Hester
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, UK
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Vas P, Chockalingam N. Improving Physical, Physiological, and Psychological Health Outcomes in Patients with Diabetic Foot Ulcers - State of the Art. Clin Cosmet Investig Dermatol 2023; 16:3547-3560. [PMID: 38107668 PMCID: PMC10725647 DOI: 10.2147/ccid.s333660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 11/30/2023] [Indexed: 12/19/2023]
Abstract
Diabetic foot disease is a complex and challenging complication of diabetes mellitus, which imposes a significant burden of disease on patients, their carers, and the wider health systems. Recurrence rates are high, and current evidence indicates a high mortality associated with it. While management algorithms have primarily focused on the physical aspects of healing, there is increasing recognition of the critical role played by psychological and biomechanical factors in the development and resolution of diabetic foot disease. Therefore, in this paper, we aim to explore how diabetic foot outcomes can be improved by addressing not only the physical but also the psychological and biomechanical aspects that are integral to the development of this condition and its optimal resolution. We explore new technologies that allow for non-invasive objective assessment of the diabetic foot at risk, and we also explore the role of understanding biomechanics, which is essential to determining risk of foot disease, but also the potential for recurrence. In addition, we discuss the evidence linking depression and cognitive impairment to diabetic foot disease and offer our insight on the research direction required before implementing novel information into front-line clinics.
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Affiliation(s)
- Prashanth Vas
- Department of Diabetes and Diabetic Foot, King’s College Hospital NHS Foundation Trust, London, UK
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke on Trent, UK
- Department of Diabetes and Endocrinology, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - Nachiappan Chockalingam
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke on Trent, UK
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Howard T, Ahluwalia R, Papanas N. The Advent of Artificial Intelligence in Diabetic Foot Medicine: A New Horizon, a New Order, or a False Dawn? INT J LOW EXTR WOUND 2023; 22:635-640. [PMID: 34488463 DOI: 10.1177/15347346211041866] [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] [Indexed: 11/15/2022]
Abstract
In a world where automation is becoming increasingly common, easier collection of mass of data and powerful computer processing has meant a transformation in the field of artificial intelligence (AI). The diabetic foot is a multifactorial problem; its issues render it suitable for analysis, interrogation, and development of AI. The latter has the potential to deliver many solutions to issues of delayed diagnosis, compliance, and defining preventative treatments. We describe the use of AI and the development of artificial neural networks that may supplement the failed networks in the diabetic foot. The potential of this technology, current developing applications, and their limitations for diabetic foot care are suggested.
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Affiliation(s)
| | - Raju Ahluwalia
- King's College Hospital, London, UK
- King's Diabetic Foot Clinic, King's College Hospital, London, UK
| | - Nikolas Papanas
- Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupoli, Greece
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9
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Meloni M, Andreadi A, Ruotolo V, Romano M, Bellizzi E, Giurato L, Bellia A, Uccioli L, Lauro D. Hospital Readmission in Patients With Diabetic Foot Ulcers: Prevalence, Causes, and Outcomes. INT J LOW EXTR WOUND 2023:15347346231207747. [PMID: 37849322 DOI: 10.1177/15347346231207747] [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: 10/19/2023]
Abstract
The aim of the current study was to evaluate the rate of readmission in patients affected by diabetes and foot ulcers (DFUs), and causes and outcomes of patients requiring a new hospitalization. The current study is a retrospective observational study including patients who have required hospitalization since January 2019 to September 2022 due to a DFU. Once patients were discharged, they were regularly followed as outpatients. Within 6 months of follow-up, the rate of hospital readmission for a diabetic foot problem was recorded. According to the readmission or not, patients were divided into 2 groups, readmitted and not readmitted patients, respectively. Hence, all patients were followed for 6 months more and outcomes of the 2 groups were analyzed and compared. Overall, 310 patients were included. The mean age was 68 ± 12 years, the majority of patients reported type 2 diabetes (>90%), and the mean diabetes duration was approximately 20 years. Sixty-eight (21.9%) patients were readmitted. The main reason for hospital readmission was the presence of critical limb ischemia (CLI) in the contralateral limb (6.1%), the recurrence of CLI in the previous treated limb (4.5%), and the onset of new infected DFU in the contralateral foot (4.5%). Readmitted patients reported lower rate of healing (51.5% vs 89.2%, P < .0001) and higher rate of major amputation (10.3% vs 4.5%, P = .2) in comparison to not readmitted patients. Critical limb ischemia resulted in the only independent predictor of hospital readmission. Hospital readmission is a frequent issue among patients with DFUs, and readmitted patients showed a lower chance of wound healing. Critical limb ischemia resulted in the main cause of new hospitalization.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Aikaterini Andreadi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Valeria Ruotolo
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Maria Romano
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Ermanno Bellizzi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Laura Giurato
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Alfonso Bellia
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Luigi Uccioli
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
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Kim J, Nomkhondorj O, An CY, Choi YC, Cho J. Management of diabetic foot ulcers: a narrative review. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2023; 40:335-342. [PMID: 37735855 PMCID: PMC10626295 DOI: 10.12701/jyms.2023.00682] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 09/23/2023]
Abstract
Diabetic foot ulcers (DFUs) are among the most serious complications of diabetes and are a source of reduced quality of life and financial burden for the people involved. For effective DFU management, an evidence-based treatment strategy that considers the patient's clinical context and wound condition is required. This treatment strategy should include conventional practices (surgical debridement, antibiotics, vascular assessment, offloading, and amputation) coordinated by interdisciplinary DFU experts. In addition, several adjuvant therapies can be considered for nonhealing wounds. In this narrative review, we aim to highlight the current trends in DFU management and review the up-to-date guidelines.
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Affiliation(s)
- Jahyung Kim
- Department of Orthopaedic Surgery, Armed Forces Yangju Hospital, Yangju, Korea
| | - Otgonsaikhan Nomkhondorj
- Department of Orthopaedic Surgery, Hallym University Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Chi Young An
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Ye Chan Choi
- Department of Orthopaedic Surgery, Hallym University Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Hallym University Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
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Papanas N, Popovic DS. Beta-Catenin Signaling Pathway: Perhaps We Should Start Exploring it for Diabetic Foot Ulcer Healing? INT J LOW EXTR WOUND 2023; 22:441-443. [PMID: 34213961 DOI: 10.1177/15347346211029818] [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] [Indexed: 10/21/2022]
Abstract
Diabetic foot ulcers (DFUs) remain a common debilitating and costly complication of diabetes mellitus. Indeed, despite all efforts and emerging technologies, many DFUs are difficult to heal and frequently recur. Thus, novel therapeutic approaches are urgently needed. Specific targeting of different molecular and cellular pathways implicated in wound healing emerges as an attractive therapeutic modality to improve outcomes. One of the novel pathways that carry this potential is the wingless-type mouse mammary tumor virus integration site family/beta-catenin signaling pathway (WβcSP). It plays an important role in different stages of wound healing, including inflammation, proliferation, and remodeling. Potential therapeutic implications of WβcSP activation include producing agonists and/or blocking its endogenous inhibitors. Thus, we should perhaps start exploring potential ways of its therapeutic implication to improve DFU healing.
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Affiliation(s)
- Nikolaos Papanas
- Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Djordje S Popovic
- Clinical Centre of Vojvodina, Novi Sad, Serbia
- Medical Faculty, University of Novi Sad, Novi Sad, Serbia
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12
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Lin JHX, Papanas N, Zayed H, Vas PRJ. Revascularisation Options for Chronic Limb Threatening Ischaemia in Diabetes: Implications From Two Recent Trials. INT J LOW EXTR WOUND 2023:15347346231188874. [PMID: 37464779 DOI: 10.1177/15347346231188874] [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: 07/20/2023]
Abstract
Chronic limb-threatening ischaemia (CLTI) is a severe form of peripheral arterial disease (PAD) and is associated with an increased risk of amputation, mortality, and significantly impaired quality of life. International guidelines recommend considering timely revascularisation and optimal medical therapy to improve limb perfusion in individuals with CLTI. The 2 primary revascularization approaches for CLTI are open bypass surgery (BS) and endovascular therapy (EV), however, there is currently no consensus on the best initial treatment strategy for CLTI, leading to uncertainty among clinicians. To shed light on this issue, 2 recent trials, namely best endovascular versus best surgical therapy in patients with CLI (BEST-CLI) and bypass versus angioplasty for severe ischaemia of the leg (BASIL-2), have tried to provide valuable insights. While a definitive conclusion on the optimal revascularisation approach is still pending, these trials offer immediate and clinically relevant information to the diabetic foot multidisciplinary team. The trials encompassed a distinct range of patient cohorts and included participants with varying degrees of medical and physical frailty. Taken together, their findings, highlight the need for an individualised revascularisation strategy which accounts for underlying comorbidities, risk factors, disease severity, availability of suitable bypass conduits, surgical risks, and timely access to procedures. Regardless of the chosen strategy, early referral of patients with diabetes and CLTI to a specialist team within a multidisciplinary environment is crucial. Comprehensive care should encompass essential elements such as adequate debridement, infection control, offloading, glycaemic control, smoking cessation, and patient education. By addressing these aspects, healthcare providers can optimise the management and outcomes for individuals with CLTI and diabetes.
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Affiliation(s)
- Jaime H X Lin
- Diabetes and Diabetic Foot, King's College NHS Foundation Trust, London, UK
- Department of Medicine, Woodlands Health, Singapore
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Hany Zayed
- Vascular Surgical Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Prashanth R J Vas
- Diabetes and Diabetic Foot, King's College NHS Foundation Trust, London, UK
- King's College London, UK
- King's Health Partners' Institute of Diabetes, Endocrinology and Obesity, London, UK
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Yong E, Gong H, Liew H, Chan YM, Neo S, Pan Y, Pua U, Lo ZJ, Zhang L, Mak M, Chong L, Hong Q, Tan GWL, Chua MJ, Bin Mohd Fadil MF, Chandrasekar S. Getting a Foothold on Diabetic Foot Disease-Outcomes of a Multidisciplinary Clinical Pathway for Inpatient Diabetic Foot Care: A 17-Year Institutional Review. INT J LOW EXTR WOUND 2023:15347346231183740. [PMID: 37376875 DOI: 10.1177/15347346231183740] [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: 06/29/2023]
Abstract
INTRODUCTION Diabetes foot disease (DFD) contributes to poor quality of life, clinical and economic burden. Multidisciplinary diabetes foot teams provide prompt access to specialist teams thereby improving limb salvage. We present a 17-year review of an inpatient multidisciplinary clinical care path (MCCP) for DFD in Singapore. METHODS This was a retrospective cohort study of patients admitted for DFD and enrolled in our MCCP to a 1700-bed university hospital from 2005 to 2021. RESULTS There were 9279 patients admitted with DFD with a mean of 545 (±119) admissions per year. The mean age was 64 (±13.3) years, 61% were Chinese, 18% Malay and 17% Indian. There was a higher proportion of Malay (18%) and Indian (17%) patients compared to the country's ethnic composition. A third of the patients had end stage renal disease and prior contralateral minor amputation. There was a reduction in inpatient major lower extremity amputation (LEA) from 18.2% in 2005 to 5.4% in 2021 (odds ratio 0.26, 95% confidence interval 0.16-0.40, P < .001) which was the lowest since pathway inception. Mean time from admission to first surgical intervention was 2.8 days and mean time from decision for revascularization to procedure was 4.8 days. The major-to-minor amputation rate reduced from 1.09 in 2005 to 0.18 in 2021, reflecting diabetic limb salvage efforts. Mean and median length of stay (LOS) for patients in the pathway was 8.2 (±14.9) and 5 (IQR = 3) days, respectively. There was a gradual trend of increase in the mean LOS from 2005 to 2021. Inpatient mortality and readmission rate was stable at 1% and 11%. CONCLUSION Since the institution of a MCCP, there was a significant improvement in major LEA rate. An inpatient multidisciplinary diabetic foot care path helped to improve care for patients with DFD.
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Affiliation(s)
- Enming Yong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Haiqing Gong
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Huiling Liew
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yam Meng Chan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Shufen Neo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Ying Pan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Uei Pua
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Zhiwen Joseph Lo
- Vascular Surgery Service, Department of Surgery, Woodlands Health, Singapore, Singapore
| | - Li Zhang
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Malcolm Mak
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Lester Chong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Qiantai Hong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Glenn Wei Leong Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Min Jia Chua
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Formosa C, Chockalingam N, Gatt A, Papanas N. Diabetic Amputations in 2023 are Still More Frightening Than Death-Act Now Before it is Too Late. INT J LOW EXTR WOUND 2023:15347346231171439. [PMID: 37081813 DOI: 10.1177/15347346231171439] [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: 04/22/2023]
Abstract
Despite huge medical and technological advances to date for the diagnosis, monitoring, and management of diabetic foot complications, their prevalence is still alarmingly high. Patients' quality of life may be severely compromised. Patients may fear amputations more than death. An effort to minimize the impact of these complications and to ensure prompt access to care for everyone is still required. Urgent therapeutic measures should become possible when needed. Improved physician training in and management of peripheral arterial disease are also vital. We need to act now before it is too late. This will definitely be one of the greatest challenges for 2023 and the years to come.
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Affiliation(s)
- Cynthia Formosa
- Faculty of Health Sciences, University of Malta, Msida, Malta
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke on Trent, UK
| | - Nachiappan Chockalingam
- Faculty of Health Sciences, University of Malta, Msida, Malta
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke on Trent, UK
| | - Alfred Gatt
- Faculty of Health Sciences, University of Malta, Msida, Malta
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke on Trent, UK
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
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15
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Carro GV, de Jesus FM, Ricci A. Diabetic Foot Osteomyelitis: Is it all the Same? INT J LOW EXTR WOUND 2023:15347346231160614. [PMID: 36883207 DOI: 10.1177/15347346231160614] [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: 03/09/2023]
Abstract
Diabetic foot osteomyelitis (OM) requires a longer duration of therapy, a greater need for surgery and implies a higher rate of recidivism, a higher amputation risk, and lower treatment success. But do all bone infections behave the same way, require the same treatment, or imply the same prognosis? Actually, in clinical practice we can verify there are different clinical presentations of OM. The first one is that associated with the infected diabetic foot attack. It requires urgent surgery and debridement since "time is tissue." Clinical features and radiographs are enough for the diagnosis, and treatment should not be delayed. The second one is related to a sausage toe. It affects phalanges and it can be treated with a 6- or 8-week antibiotic course with a high rate of success. Clinical features and radiographs are sufficient for the diagnosis in this case. The third presentation is OM superimposed to Charcot's neuroarthropathy, which mainly comprises midfoot or hindfoot. It starts with a plantar ulcer in a foot that has developed a deformity. The treatment is based on an accurate diagnosis that often includes magnetic resonance, and requires a complex surgery to preserve the midfoot and to avoid recurrent ulcers or foot instability. The final presentation is that of an OM without large soft tissue compromise secondary to a chronic ulcer or a previous unsuccessful surgery secondary to minor amputation or debridement. There is often a small ulcer with a positive probe to bone test over a bony prominence. Diagnosis is made by clinical features, radiographs, and laboratory tests. Treatment includes antibiotic therapy guided by surgical or transcutaneous biopsy, but this presentation often requires surgery. Different presentations of OM mentioned above need to be recognized because the diagnosis, type of culture, antibiotic treatment, surgical treatment, and prognosis are different upon the presentation.
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Affiliation(s)
| | | | - Anahí Ricci
- Hospital Nacional Prof. A. Posadas, El Palomar, Buenos Aires, Argentina
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16
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Ahmed ME, Mohammad KMK, Mahadi SI, Widyatalla AH. Management of diabetic ulcers of the dorsum of the foot and distal leg ulcers. J Wound Care 2022; 31:941-945. [DOI: 10.12968/jowc.2022.31.11.941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: Diabetic foot ulceration of toes, forefoot and heel have been extensively studied; however, the dorsum of the foot and the distal leg have rarely been addressed. The objective of this study was to assess diabetic ulcers of the dorsum of the foot and of the distal leg (DUDFDLs) as primary sites, or extended lesions from other foot locations, with regard to possible causes, management and outcomes. Method: This was a retrospective study conducted in Jabir Abu Eliz Diabetic Centre (JADC) in Khartoum from January 2018 to August 2019. All patients with a primary DUDFDL, or one extending from a plantar or heel ulcer, were included. Results: A cohort of 102 patients with DUDFDLs were studied; 74 (72.5%) were male and 28 (27.5%) were female, with a male-to-female ratio of 2.6:1, and a mean age of 57±12 years. The ulcer was a primary DUDFDL in 38 patients and a secondary ulcer in 64 patients. The outcome in 38 patients with primary DUDFDL was healing without amputation in 26 cases (68.4%), amputation of toes in 12 cases (31.6%), and no major amputation or death. Of the 64 patients presenting with secondary DUDFDL extending from the plantar surface, there was extension to the dorsum of the foot through the forefoot ulcer in 54 patients and through the ankle joint to the distal leg in 10 patients. For the plantar ulcers extending to the dorsum, five cases healed without amputation (9.3%), minor amputation was necessary in 29 cases (53.7%), major amputation in 14 cases (25.9%) and six patients died (11.1%). For the distal leg ulcers with extension through the ankle joint, five healed without amputation and five required minor amputation. Conclusion: Primary DUDFDLs had a favourable outcome. Dorsum extension of diabetic foot ulcer from the plantar aspect of the foot carries a high risk for major limb amputation and death.
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Affiliation(s)
- Mohamed Elmakki Ahmed
- Jabir Abu Eliz Diabetic Centre, Khartoum, Sudan
- Department of Surgery, University of Khartoum, Sudan
| | | | - Seifeldin Ibrahim Mahadi
- Jabir Abu Eliz Diabetic Centre, Khartoum, Sudan
- Department of Surgery, University of Khartoum, Sudan
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17
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Kurze C, Farn CJ, Siow J. The Interdisciplinary Approach: Preventive and Therapeutic Strategies for Diabetic Foot Ulcers. Foot Ankle Clin 2022; 27:529-543. [PMID: 36096550 DOI: 10.1016/j.fcl.2022.03.001] [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] [Indexed: 02/02/2023]
Abstract
The appropriate treatment of the common diabetic foot ulcers (DFUs) in diabetic patients demands enormous human, organizational and financial resources that are finite. Interdisciplinary teams of medical and surgical specialists, as well as allied health professionals, can help to reduce the consumption of these resources, optimize treatment, and prevent DFUs. They consist primarily of vascular surgeons, endocrinologists, and orthopedic foot and ankle surgeons and are closely supported when required by infectious diseases specialists, plastic surgeons, wound care specialist nurses, podiatrists, and orthotists. A timely interdisciplinary team review in each clinic session decreases the number of hospital visits for the oftentimes-handicapped diabetic patients significantly. The interdisciplinary team clinic setup has also been shown to reduce the risk of amputations, length of hospital staz and mortality rates.
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Affiliation(s)
- Christophe Kurze
- Department of Orthopedic Surgery, Inselspital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerland.
| | - Chui Jia Farn
- Department of Orthopedic Surgery, Inselspital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerland; Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - James Siow
- Department of Orthopedic Surgery, Inselspital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerland; Department of Orthopedic Surgery, Woodlands Health, Singapore
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18
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Diabetic Foot Limb Threatening Infections: Case Series and Management Review. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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19
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Balikji J, Kiani P, Hendriksen PA, Hoogbergen MM, Garssen J, Verster JC. Impaired wound healing is associated with poorer mood and reduced perceived immune fitness during the COVID‐19 pandemic: A retrospective survey. Health Sci Rep 2022; 5:e764. [PMID: 35949670 PMCID: PMC9358545 DOI: 10.1002/hsr2.764] [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: 04/12/2022] [Revised: 05/19/2022] [Accepted: 06/19/2022] [Indexed: 11/12/2022] Open
Abstract
Background and Aims Methods Results Conclusion
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Affiliation(s)
- Jessica Balikji
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University Utrecht The Netherlands
| | - Pantea Kiani
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University Utrecht The Netherlands
| | - Pauline A. Hendriksen
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University Utrecht The Netherlands
| | | | - Johan Garssen
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University Utrecht The Netherlands
- Global Centre of Excellence Immunology Nutricia Danone Research Utrecht The Netherlands
| | - Joris C. Verster
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University Utrecht The Netherlands
- Centre for Human Psychopharmacology Swinburne University Melbourne Victoria Australia
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20
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Deng L, Xie P, Chen Y, Rui S, Yang C, Deng B, Wang M, Armstrong DG, Ma Y, Deng W. Impact of acute hyperglycemic crisis episode on survival in individuals with diabetic foot ulcer using a machine learning approach. Front Endocrinol (Lausanne) 2022; 13:974063. [PMID: 36093085 PMCID: PMC9452661 DOI: 10.3389/fendo.2022.974063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/10/2022] [Indexed: 11/21/2022] Open
Abstract
Objective The outcome of DFUs concomitant with HCE remains unknown. This study aimed to investigate mortality rates and identify risk factors of mortality in patients with DFUs-HCE. Methods 27 inpatients with DFUs-HCE were retrospectively enrolled in a cohort design, they were compared to 93 inpatients with DFUs in a city designated emergency center, between January 2016 and January 2021. After a 6-year followed-up, clinical characteristic, amputation and survival rates were compared. Extreme gradient boosting was further used to explore the relative importance of HCE and other risk factors to all-cause mortality in DFUs. Results Patients with DFUs-HCE were more likely to havedementia, acute kidney injury and septic shock, whereas DFUs were more likely to have diabetic peripheral neuropathy and ulcer recurrence (P<0.05). No significant difference was observed on the amputation rate and diabetes duration. Both Kaplan-Meier curves and adjusted Cox proportional model revealed that DFUs-HCE was associated with a higher mortality compared with DFUs (P<0.05). HCE significantly increased the risk of mortality in patients with DFUs (hazard ratio, 1.941; 95% CI 1.018-3.700; P = 0.044) and was independent from other confounding factors (age, sex, diabetes duration, Wagner grades and Charlson Comorbidity Index). The XGBoost model also revealed that HCE was one of the most important risk factors associated with all-cause mortality in patients with DFUs. Conclusions DFUs-HCE had significantly lower immediate survival rates (first 1-6 month) than DFUs alone. HCE is an important risk factor for death in DFUs patients.
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Affiliation(s)
- Liling Deng
- Department of Endocrinology and School of Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - Puguang Xie
- Department of Endocrinology and School of Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - Yan Chen
- Department of Endocrinology and School of Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - Shunli Rui
- Department of Endocrinology and School of Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - Cheng Yang
- Department of Endocrinology and School of Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - Bo Deng
- Department of Endocrinology and School of Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - Min Wang
- Department of Endocrinology and School of Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - David G. Armstrong
- Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Yu Ma
- Department of Endocrinology and School of Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - Wuquan Deng
- Department of Endocrinology and School of Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
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21
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Wang F, Zhou L, Zhu D, Yang C. A Retrospective Analysis of the Relationship Between 25-OH-Vitamin D and Diabetic Foot Ulcer. Diabetes Metab Syndr Obes 2022; 15:1347-1355. [PMID: 35535217 PMCID: PMC9078343 DOI: 10.2147/dmso.s358170] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/27/2022] [Indexed: 11/23/2022] Open
Abstract
Background The fat-soluble molecule vitamin D has attracted much attention since its pleiotropism was discovered. Its effectiveness can be attributed to the presence of vitamin D receptors in most of the body's tissues. Based on the classical role of vitamin D in regulating calcium and phosphorus metabolism and maintaining bone health, the role of vitamin D in immunity, type 2 diabetes mellitus (T2DM), tumor and cardiovascular diseases has been further discovered. Some experiments have shown that vitamin D can restore the production of antimicrobial peptides (AMP) in primary diabetic foot ulcer (DFU) cells, which can improve in vitro wound healing, indicating its potential therapeutic use in DFU therapy. In addition, vitamin D can also inhibit the secretion of T-helper type 1 (Th1) cytokines IFN-Y and IL-2 while stimulating the production of Th2 cytokines, thereby promoting wound healing. Objective To investigate the relationship between 25-OH-vitamin D level and DFU in diabetes mellitus (DM) patients, and to provide a theoretical basis for the early prevention and treatment of DFU. Methods The clinical data of 429 hospitalized patients with DM were retrospectively analyzed in this case-control study. The patients were divided into the DFU group (n = 242) and non-DFU group (n = 187). Fasting venous blood was drawn from all subjects to detect serum 25-OH-vitamin D levels and blood biochemical parameters, the difference of parameters between DFU group and non-DFU group were analyzed, and the risk factors of DFU were analyzed by logistic regression. Results The difference between the two groups in age, DM duration, gender, diastolic blood pressure, serum creatinine, total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, alanine aminotransferase, aspartate aminotransferase, albumin, white blood cell count, hemoglobin, hematocrit, 25-OH-vitamin D was statistically significant (p < 0.05). Multivariate logistic regression analysis showed that 25-OH-vitamin D is an independent protective factor for DFU [OR 95%, CI 0.984 (0.969, 0.998), p < 0.05]. 25-OH-vitamin D nutrition status distribution was different between non-DFU group and DFU group (P < 0.05). Vitamin D deficiency (< 50 nmol/L) accounted for 86.78% of all DFU patients, which was only 74.33% in non-DFU patients. The 25-OH-vitamin D levels of DFU patients from Wagner Grades 1 to 5 showed a downward trend (p < 0.01). Conclusion In conclusion, our study confirms that 25-OH-vitamin D is closely correlated with DFU and that 25-OH-vitamin D is an independent protective factor for DFU. Therefore, vitamin D screening or supplementation might be beneficial to prevent DFU and improve the prognosis of DM patients.
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Affiliation(s)
- Fenglin Wang
- Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
- Department of Endocrinology, Air Force Medical Center, Beijing, 100142, People’s Republic of China
| | - Luyao Zhou
- Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Di Zhu
- Department of Endocrinology, Air Force Medical Center, Beijing, 100142, People’s Republic of China
| | - Caizhe Yang
- Department of Endocrinology, Air Force Medical Center, Beijing, 100142, People’s Republic of China
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22
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Meloni M, Giurato L, Panunzi A, Bellia A, Bohbot S, Lauro D, Uccioli L. Effectiveness of Sucrose Octasulfate Dressing in the Treatment of Neuro-Ischaemic Diabetic Foot Heel Ulcers: A Retrospective Single arm Study. INT J LOW EXTR WOUND 2022:15347346221087499. [PMID: 35287510 DOI: 10.1177/15347346221087499] [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: 11/17/2022]
Abstract
The study aimed to evaluate the effectiveness of the use of sucrose octasulfate impregnated dressing (TLC-NOSF [Technology Lipido-Colloid-Nano-OligoSaccharide Factor]) in the management of persons with neuro-ischaemic heel diabetic foot ulcers (DFUs). Consecutive patients who referred for an active non-infected neuro-ischaemic heel DFU belonging to grade IC (superficial) or IIC (deep to tendons, muscle or capsule) according to Texas University Classification were included. All patients were managed by a pre-set limb salvage protocol in the respect of International guidelines and the TLC-NOSF dressing was used as primary and specific dressing. Patients were evaluated any 2 to 4 weeks until wound healing or different outcomes. Primary outcome was the rate of complete wound healing after 24 weeks of follow-up. The secondary outcomes assessed the healing time, the rate of wound regression, the re-ulceration in the case of complete healing and the safety. Thirty patients were included. The mean age was 67 ± 11 years, 17 (56.7%) were male, all of them were affected by type 2 diabetes with a mean duration of 18 ± 7 years. Twenty patients (66.7%) showed deep ulcers (grade 2 of Texas University Classification); the mean TcPO2 at the inclusion was 42 ± 7 mm Hg. Twenty-two patients (73.3%) healed by Week 24. The mean time of healing was 84 ± 32 days, 2 (6.7%) patients had ulcer relapse after healing, 28 (93.3%) had wound regression >50%, 2 (6.7%) had mild infection, 1 (3.3%) reported major amputation. No serious adverse events related to TLC-NOSF dressing or local reactions were reported. This current study showed the potential benefit of sucrose octasulfate for treating neuro-ischaemic heel DFUs in addition to the standard of care.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
| | - Laura Giurato
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
| | - Andrea Panunzi
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
| | - Alfonso Bellia
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
| | | | - Davide Lauro
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
| | - Luigi Uccioli
- Department of Systems Medicine, 9318University of Rome Tor Vergata, Rome, Italy
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23
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Kavarthapu V, Budair B. Two-stage reconstruction of infected Charcot foot using internal fixation : a promising functional limb salvage technique. Bone Joint J 2021; 103-B:1611-1618. [PMID: 34587806 DOI: 10.1302/0301-620x.103b10.bjj-2021-0339.r2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. METHODS We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months' follow-up. RESULTS We identified 23 feet in 22 patients with a mean age of 56.7 years (33 to 70). The mean postoperative follow-up period was 44.7 months (14 to 99). Limb salvage was achieved in all patients. At one-year follow-up, all ulcers have healed and independent full weightbearing mobilization was achieved in all but one patient. Seven patients developed new mechanical skin breakdown; all went on to heal following further interventions. Fusion of the hindfoot was achieved in 15 of 18 feet (83.3%). Midfoot fusion was achieved in nine of 15 patients (60%) and six had stable and painless fibrous nonunion. Hardware failure occurred in five feet, all with broken dorsomedial locking plate. Six patients required further surgery, two underwent revision surgery for infected nonunion, two for removal of metalwork and exostectomy, and two for dynamization of the hindfoot nail. CONCLUSION Two-stage reconstruction of the infected and deformed Charcot foot using internal fixation and following the principle of 'long-segment, rigid and durable internal fixation, with optimal bone opposition and local antibiotic elusion' is a good form of treatment provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2021;103-B(10):1611-1618.
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Affiliation(s)
- Venu Kavarthapu
- Trauma and Orthopaedics, King's College Hospital NHS Foundation Trust, London, UK.,University of Southern Denmark, Odense, Denmark
| | - Basil Budair
- Trauma & Orthopaedics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Aston University School of Engineering and Applied Science, Birmingham, UK
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Ahluwalia R, Lázaro-Martínez JL, Reichert I, Maffulli N. Advances in pharmacotherapy for diabetic foot osteomyelitis. Expert Opin Pharmacother 2021; 22:2281-2291. [PMID: 34323622 DOI: 10.1080/14656566.2021.1954159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introduction: The diagnosis of diabetic foot osteomyelitis (DFO) is usually clinical. Its severity is related to the location and depth of the lesion, and the presence of necrosis or gangrene. The aetiology of diabetic foot osteomyelitis (DFO) is usually polymicrobial, and DFO is often associated with chronic or recurring ulceration.Areas covered: We built on the International Working Group on the Diabetic Foot (IWGDF) guidelines on the management of diabetic foot infection, providing an outline of the current and new concepts in pharmacotherapy in DFO. We assess future strategies in both medical, surgical and combination management of DFO.Expert opinion: Surgical removal of infected bone is considered as the standard treatment, but a medical approach of certain selected situations has now proven efficacy in selected patients. The combination of new modalities in local antibiotic delivery may provide better long-term solutions and more lasting remission and avoid the disadvantages of prolonged systemic antibiotics.
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Affiliation(s)
- Raju Ahluwalia
- Department of Trauma & Orthopaedics, Kings College Hospital London
| | - Jose Luiz Lázaro-Martínez
- Diabetic Foot Unit, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital, Clínico San Carlos (Idissc), Madrid, Spain
| | - Ines Reichert
- Department of Trauma & Orthopaedics, Kings College Hospital London
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Faculty of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (SA), Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, UK.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK
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25
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Frykberg RG, Attinger C, Smeets L, Koller A, Bal A, Kavarthapu V. Surgical strategies for prevention of amputation of the diabetic foot. J Clin Orthop Trauma 2021; 17:99-105. [PMID: 33738238 PMCID: PMC7944028 DOI: 10.1016/j.jcot.2021.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 12/28/2022] Open
Abstract
Prevention of amputation has become a key objective of clinicians providing care to patients with high-risk diabetic foot problems. In this regard, the multidisciplinary diabetic foot team (MDFT) has been embraced as the most effective way to manage patients with foot ulcers, infections, and Charcot feet. Importantly, such specialized teams have also integrated various surgical specialties to enable more expedient management of these often complex conditions. Experienced diabetic foot surgeons over the last three or four decades have contributed much to this discipline, whereby foot-sparing reconstructive procedures or minor amputations have become fundamental strategies for limb preservation teams. Central to limb salvage, of course, is the recognition of underlying vascular insufficiency and the importance of prompt (endo)vascular intervention. Restoration of adequate perfusion is essential to allow the podiatric, orthopaedic, or plastic surgeon to perform indicated functional reconstructive or minor amputation procedures. This evidence-based overview discusses the various indications and surgical principles inherent in modern concepts aimed at preventing amputation in the high-risk diabetic foot.
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Affiliation(s)
| | - Christopher Attinger
- Departments of Plastic and Orthopedic Surgery, Medstar Georgetown University Hospital, USA
| | | | - Armin Koller
- Department of Technical Orthopaedics, Dr. Guth Hospital, Hamburg, Germany
| | - Arun Bal
- Fortis Raheja Hospital, Mumbai, India
| | - Venu Kavarthapu
- King’s College Hospital, London, UK
- University of Southern Denmark, Denmark
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26
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Ahluwalia R, Reichert I. Surgical management of the acute severely infected diabetic foot - The 'infected diabetic foot attack'. An instructional review. J Clin Orthop Trauma 2021; 18:114-120. [PMID: 33996456 PMCID: PMC8102754 DOI: 10.1016/j.jcot.2021.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 01/13/2023] Open
Abstract
Diabetic Foot Infection (DFI), in its severest form the acute infected 'diabetic foot attack', is a limb and life threatening condition if untreated. Acute infection may lead to tissue necrosis and rapid spread through tissue planes, in the patient with poorly controlled diabetes facilitated by the host status. A combination of soft tissue infection and osteomyelitis may co-exist, in particular if chronic osteomyelitis serves as a persistent source for recurrence of soft tissue infection. This "diabetic foot attack" is characterised by acutely spreading infection and substantial soft tissue necrosis. In the presence of ulceration, the condition is classified by the Infectious Diseases Society of America/International Working Group on the Diabetic Foot (IDSA/IWGDF Class 3 or 4) presentation requiring an urgent surgical intervention by radical debridement of the infection. Thus, 'time is tissue', referring to tissue salvage and maximal limb preservation. Emergent treatment is important for limb salvage and may be life-saving. We provide a narrative current treatment practices in managing severe DFI with severe soft tissue and osseous infection. We address the role of surgery and its adjuvants, the long term outcomes, potential complications and possible future treatment strategies.
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Affiliation(s)
- R.S. Ahluwalia
- Corresponding author. King’s College Hospital NHS Trust, Bessemer Road, London, SE5 9RS, United Kingdom.
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27
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Meloni M, Acquati S, Licciardello C, Ludovico O, Sepe M, Vermigli C, Da Ros R. Barriers to diabetic foot management in Italy: A multicentre survey in diabetic foot centres of the Diabetic Foot Study Group of the Italian Society of Diabetes (SID) and Association of Medical Diabetologists (AMD). Nutr Metab Cardiovasc Dis 2021; 31:776-781. [PMID: 33549455 DOI: 10.1016/j.numecd.2020.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Diabetic foot (DF) disease is a current health and social burden. The authors aimed to identify the barriers to the DF management across Italy. METHODS AND RESULTS A questionnaire was submitted to Italian centres dedicated to DF care. The questionnaire was composed of 12 questions focused on the barriers to the DF management including timing of referral, hospital management, and community follow-up. Each centre could answer by choosing a score from 1 to 5 for every item with the following numerical variables: 1 = never; 2 = rarely; 3 = sometimes; 4 = often; 5 = always. Accordingly, for each item a national and regional score was reported and a comparison between regions was carried out. National and regional scores were estimated using the total score for each item as a numerator and the number of national centres included as a denominator. Among 102 centres, 99 were included and 3 were excluded due to missing data. The 99 centres belonged to 16 regions with the following distribution: Calabria 4, Campania 5, Emilia-Romagna 14, Friuli-Venezia-Giulia 4, Lazio 12, Liguria 4, Lombardy 10, Marche 1, Molise 1, Piedmont 5, Apulia 5, Sardinia 5, Sicily 4, Tuscany 11, Veneto 9, Umbria 5. The items with the highest score were late referral (3.3) and urgent surgery (3.2). The regions with the highest score were Molise (3.9) and Calabria (3.5). CONCLUSION The main issues across Italy were late referral and the requirement for urgent surgery for acute DF. In the regional scenario, the southern central areas showed more barriers than northern regions.
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Affiliation(s)
- Marco Meloni
- Diabetic Foot Unit, Department of Systems Medicine, University of Rome Tor Vergata, Italy.
| | - Silvia Acquati
- Unit of Endocrinology, Pierantoni-Morgagni Hospital, Forlì AUSL Romagna, Italy
| | - Carmelo Licciardello
- UFC Malattie disendocrine e dismetaboliche, Centro Catanese di Medicina e Chirurgia, Catania, Italy
| | - Ornella Ludovico
- Unit of Endocrinology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | | | - Cristiana Vermigli
- Unit of Endocrinology, Diabetic Foot Centre, University Hospital Santa Maria della Misericordia, Perugia, Italy
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28
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Phillips A, Edmonds M. ACT NOW in diabetes and foot assessments: an essential service. Br J Community Nurs 2021; 26:116-120. [PMID: 33719551 DOI: 10.12968/bjcn.2021.26.3.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anne Phillips
- Associate Professor in Diabetes Care, Birmingham City University; Co-chair of iDEAL Diabetes
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29
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Meloni M, Bouillet B, Ahluwalia R, Lüdemann C, Sánchez‐Ríos JP, Iacopi E, Lazaro‐Martinez JL. Fast-track pathway for diabetic foot ulceration during COVID-19 crisis: A document from International Diabetic Foot Care Group and D-Foot International. Diabetes Metab Res Rev 2021; 37:e3396. [PMID: 32804425 PMCID: PMC7460948 DOI: 10.1002/dmrr.3396] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 08/07/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Marco Meloni
- Diabetic Foot CenterUniversity of Tor VergataRomeItaly
| | | | - Raju Ahluwalia
- Department of Trauma and Ortophaedic DepartmentKing's College HospitalLondonUK
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30
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Huang C, Wang R, Yan Z. Silver dressing in the treatment of diabetic foot: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24876. [PMID: 33607864 PMCID: PMC7899903 DOI: 10.1097/md.0000000000024876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Diabetic foot (DF) is one of the most common and serious chronic complications of diabetes. At present, there are many dressings used in the treatment of the diabetic foot. Among them, silver dressings are widely used, but the conclusion has not yet been formed. The purpose of this study is to search for relevant studies on the treatment of DF with silver dressings through evidence-based medicine methods and to draw conclusions with higher levels of evidence to provide a basis for the clinical treatment of DF. METHODS Computer search of databases such as CNKI, SinoMed, VIP, Wanfang, PubMed, Embase, and Cochrane Library. The search time is from the establishment of the database to January 23, 2021. Two researchers will independently select studies, collect data, and assess the methodology quality by the Cochrane risk of bias tool. The meta-analysis will be completed by RevMan 5.3 software. RESULTS This systematic review will provide an assessment of the current state of DF, aiming to assess the efficacy of silver dressings for patients with DF. CONCLUSION This systematic review will provide a credible evidence-based for the clinical treatment of DF with silver dressings.
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Affiliation(s)
- Chunhua Huang
- Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang
| | - Ruiqi Wang
- Jiangxi University of Traditional Chinese Medicine Nanchang, Jiangxi Province, China
| | - Zhangren Yan
- Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang
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31
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Serban D, Papanas N, Dascalu AM, Stana D, Nicolae VA, Vancea G, Badiu CD, Tanasescu D, Tudor C, Balasescu SA, Pantea-Stoian A. Diabetic Retinopathy in Patients With Diabetic Foot Ulcer: A Systematic Review. INT J LOW EXTR WOUND 2020; 20:98-103. [PMID: 33353439 DOI: 10.1177/1534734620982237] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This review discusses the evidence on diabetic retinopathy (DR) in patients with diabetic foot ulceration (DFU). A systematic literature review was performed on PubMed, Medline, Springer Nature, and Scopus, following the PRISMA guidelines, using the following terms, individually or in combination: "diabetic foot ulcer" OR "diabetic foot syndrome" OR "DFU" and "diabetic retinopathy." The initial search yielded 648 articles published between 1975 and 2020. After applying exclusion and inclusion criteria, a total of 9 articles were analyzed, assessing the correlations between DR and DFU. In all cases, DR and especially proliferative diabetic retinopathy were significantly higher in the presence of DFU, though the frequency of DR showed large variability (22.5% to 95.6%). There was a significant correlation between advanced stages of DFU and increased frequency of DR and proliferative diabetic retinopathy. On the other hand, there is a risk of accelerated progression of DR in nonhealing DFUs, possibly related to chronic inflammation and associated infection. Hence, patients with DFUs should be monitored by an ophthalmologist, and those with DR should be promptly referred to a specialized diabetic foot clinic.
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Affiliation(s)
- Dragos Serban
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bucharest, Romania.,Emergency University Hospital Bucharest, Bucharest, Romania
| | - Nikolaos Papanas
- Democritus University of Thrace, Alexandroupolis, Greece.,University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Ana Maria Dascalu
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bucharest, Romania.,Emergency University Hospital Bucharest, Bucharest, Romania
| | - Daniela Stana
- Emergency University Hospital Bucharest, Bucharest, Romania
| | - Vanessa Andrada Nicolae
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bucharest, Romania.,Emergency University Hospital Bucharest, Bucharest, Romania
| | - Geta Vancea
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bucharest, Romania
| | | | | | - Corneliu Tudor
- Emergency University Hospital Bucharest, Bucharest, Romania
| | | | - Anca Pantea-Stoian
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bucharest, Romania
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32
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Impact of COVID-19 Pandemic on the outcomes in patients with Critical Limb Threatening Ischaemia and Diabetic Foot Infection. Ann Surg 2020; 275:1037-1042. [PMID: 33630476 PMCID: PMC9132240 DOI: 10.1097/sla.0000000000004677] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Examine the impact of Coronavirus-2019(COVID-19) pandemic on the outcomes in patients with critical limb threatening ischemia(CLTI) or diabetic foot infection(DFI). BACKGROUND Patients with CLTI and/or DFI are at risk of amputations if not treated in a timely manner. METHODS We compared the outcomes in patients with CLTI or DFI during two periods; Period 1[P1] (15/03/2019-31/05/2019) and period 2[P2] (15/03/2020-31/05/2020- corresponding to COVID-19 pandemic). RESULTS 139 patients were treated in P1 [mean age 70 years (±11), Male:Female=102:37] while 95 patients were treated in P2 [mean age 67(±12), Male:Female=64:31]. The two cohorts were matched regarding Rutherford category (P=0.25) and GLASS classification (P=0.38). Notably, the time from onset of symptom to clinical presentation was significantly longer [31(1-105) days vs 27(0-78) days, (P=0.017)], whereas the time from presentation to first intervention was significantly shorter [3 (0-61) days vs 5 (0-65) days, (P=0.013)] in P2 compared to P1. There was a significantly higher WCC(P=0.014) and CRP(P=0.004) on admission in P2. Having treatment for CLTI or DFI in P2 was an independent predictor of worse primary patency rate and Freedom from major adverse limb events (F-MALE). At 90 days, amputation-free survival (AFS) and Limb salvage (LS) were noticeably worse in P2 compared to P1 (AFS was 80% and 87% while LS was 64% and 72% in P2 and P1 respectively). CONCLUSIONS Patients with CLTI and DFI experienced a significantly delayed presentation with features of sepsis on admission in P2. Treatment in P2 was a predictor of worse primary patency and F-MALE and therefore close and long follow-up is advisable.
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Vainieri E, Ahluwalia R, Slim H, Walton D, Manu C, Taori S, Wilkins J, Huang DY, Edmonds M, Rashid H, Kavarthapu V, Vas PRJ. Outcomes after Emergency Admission with a Diabetic Foot Attack Indicate a High Rate of Healing and Limb Salvage But Increased Mortality: 18-Month Follow-up Study. Exp Clin Endocrinol Diabetes 2020; 130:165-171. [PMID: 33352595 DOI: 10.1055/a-1322-4811] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM The diabetic foot attack (DFA) is perhaps the most devastating form of diabetic foot infection, presenting with rapidly progressive skin and tissue necrosis, threatening both limb and life. However, clinical outcome data in this specific group of patients are not available. METHODS Analysis of 106 consecutive patients who underwent emergency hospitalisation for DFA (TEXAS Grade 3B or 3D and Infectious Diseases Society of America (IDSA) Class 4 criteria). Outcomes evaluated were: 1) Healing 2) major amputation 3) death 4) not healed. The first outcome reached in one of these four categories over the follow-up period (18.4±3.6 months) was considered. We also estimated amputation free survival. RESULTS Overall, 57.5% (n=61) healed, 5.6% (n=6) underwent major amputation, 23.5% (n=25) died without healing and 13.2% (n=14) were alive without healing. Predictive factors associated with outcomes were: Healing (age<60, p=0.0017; no Peripheral arterial disease (PAD) p= 0.002; not on dialysis p=0.006); major amputation (CRP>100 mg/L, p=0.001; gram+ve organisms, p=0.0013; dialysis, p= 0.001), and for death (age>60, p= 0.0001; gram+ve organisms p=0.004; presence of PAD, p=0.0032; CRP, p=0.034). The major amputation free survival was 71% during the first 12 months from admission, however it had reduced to 55.4% by the end of the follow-up period. CONCLUSIONS In a unique population of hospitalised individuals with DFA, we report excellent healing and limb salvage rates using a dedicated protocol in a multidisciplinary setting. An additional novel finding was the concerning observation that such an admission was associated with high 18-month mortality, almost all of which was after discharge from hospital.
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Affiliation(s)
- Erika Vainieri
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Raju Ahluwalia
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Hani Slim
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Daina Walton
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Chris Manu
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Surabhi Taori
- King's College Hospital NHS Foundation Trust, London, United Kingdom.,School of Immunology & Microbial Sciences, Kings College, London, United Kingdom
| | - Jason Wilkins
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Dean Y Huang
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mike Edmonds
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Hisham Rashid
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Venu Kavarthapu
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Prashanth R J Vas
- King's College Hospital NHS Foundation Trust, London, United Kingdom.,Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, United Kingdom
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34
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Carro GV, Saurral R, Salvador Sagüez F, Witman EL. Diabetic Foot Infections: Bacterial Isolates From the Centers and Hospitals of Latin American Countries. INT J LOW EXTR WOUND 2020; 21:562-573. [PMID: 33258394 DOI: 10.1177/1534734620976305] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Diabetic foot infections (DFIs) are one of the most important reasons for lower limb amputations. An adequate approach to the management of DFI implies control of infection using strategies of tissue debridement and empirical antibiotic treatment based on local microbiology. The aim of this study was to determine the bacterial isolates profile and antibiotic susceptibility patterns in samples from DFI from Latin American centers, on the premise that microbiology of this region differs from that of other continents and influences antimicrobial election. Three hundred and eighty-two samples from soft tissue and bone were studied from 17 centers of 4 countries. Three hundred and seven (80.4%; 95% confidence interval = 75.9-84.2) were positive. Gram negatives (GN) were isolated in 43.8% of all samples, not only in severe but also in mild infections, 51% in bone samples, more frequently in presence of ischemia (47% vs 38%; P = .07) and in wounds with longer duration of the lesion (30-20 days; P < .01). Staphylococcus aureus was the most frequent single germ (19.9%). Gram positives were isolated more frequently in patients without ischemia (53% vs 40%; P = .01). Enterococcus faecalis was the most frequent germ in bone samples (16.8%). Ciprofloxacin and trimethoprim-sulfamethoxazole were the oral antimicrobials most effective against GN. Trimethoprim-sulfamethoxazole and rifampicin were the oral antimicrobials most effective against Staphylococcus. Because of GN high antibiotic resistance patterns, patients treated in an ambulatory setting have to be controlled early after starting empiric treatment to assess response to therapy and hospitalize for parenteral antibiotics if oral treatment fails.
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Affiliation(s)
| | - Ruben Saurral
- Hospital Municipal de Trauma y Emergencias Dr. Federico Abete, Buenos Aires, Argentina
| | | | - Erica Lorena Witman
- Establecimiento Asistencial Gobernador Centeno, Gral Pico, La Pampa, Argentina
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35
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Chen Y, Meng L, Wang L, Xiao L, Yang C. Establishment of a diagnostic model of coronary heart disease for patients with diabetic foot. Medicine (Baltimore) 2020; 99:e22334. [PMID: 33019409 PMCID: PMC7535636 DOI: 10.1097/md.0000000000022334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 08/18/2020] [Accepted: 08/22/2020] [Indexed: 11/26/2022] Open
Abstract
This study aims to establish a diagnostic model of coronary heart disease (CHD) for diabetic foot (DF) patients.The clinical data of 489 hospitalized patients with DF were retrospectively analyzed in this case-control study. The patients were divided into the CHD group (DF with CHD, n = 212) and the control group (DF without CHD, n = 277). Univariate analysis was performed to screen for CHD-related risk factors, and multivariate logistic regression analysis was conducted to determine significant CHD risk factors. Scores were assigned according to the ratio of risk factors (OR) to establish a diagnostic model of CHD for patients with DF. The area under the ROC curve was used to test the application value of the diagnostic model.The logistic regression analysis showed that the risk factors for CHD in DF patients were age, duration of diabetes, toe-brachial index, hyperuricemia, and chronic renal insufficiency. The area under the ROC curve of the diagnostic model was 0.798 (0.759-0.837), the diagnostic point of CHD was 6 points, the diagnostic sensitivity was 69.3%, and the specificity was 76.5%.The established model has good diagnostic value and provides the basis for preliminary screening for CHD in patients with DF.
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Affiliation(s)
- Ying Chen
- Department of Endocrinology of the Air Force Medical Center, PLA
| | - Liwei Meng
- Department of Endocrinology of the Xiangyang District People's Hospital of Xiangyang City, China
| | - Liangchen Wang
- Department of Endocrinology of the Air Force Medical Center, PLA
| | - Li Xiao
- Department of Endocrinology of the Air Force Medical Center, PLA
| | - Caizhe Yang
- Department of Endocrinology of the Air Force Medical Center, PLA
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36
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Vas PRJ, Whyte MB, Papanas N. Association between glycaemic control and diabetic foot outcomes: Dark side of the moon? J Diabetes Complications 2020; 34:107650. [PMID: 32571685 DOI: 10.1016/j.jdiacomp.2020.107650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 10/24/2022]
Affiliation(s)
- P R J Vas
- Department of Diabetes, King's College NHS Foundation Trust, London, United Kingdom; King's Health Partners' Institute of Diabetes, Endocrinology and Obesity, London, UK
| | - M B Whyte
- Department of Diabetes, King's College NHS Foundation Trust, London, United Kingdom; King's Health Partners' Institute of Diabetes, Endocrinology and Obesity, London, UK; Department of Clinical and Experimental Medicine, University of Surrey, United Kingdom
| | - N Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece.
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37
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Álvaro-Afonso FJ, García-Álvarez Y, Lázaro-Martínez JL, Kakagia D, Papanas N. Advances in Dermoepidermal Skin Substitutes for Diabetic Foot Ulcers. Curr Vasc Pharmacol 2020; 18:182-192. [PMID: 30963977 DOI: 10.2174/1570161117666190408170144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/11/2018] [Accepted: 12/21/2018] [Indexed: 11/22/2022]
Abstract
Diabetic foot ulcers (DFUs) are one of the major complications of diabetes, representing a leading cause of hospitalisation and non-traumatic lower limb amputations. Multidisciplinary management, patient education, glucose control, debridement, off-loading, infection control, and adequate perfusion are the mainstays of standard care. Despite all these, at least 30% of DFUs fail to heal within 20 weeks. Therefore, dermoepidermal skin substitutes (DSS) have been used as a new therapeutic adjunct for DFUs. This brief review outlines the recent advances in DSS for the treatment of DFUs. PubMed and Cochrane databases were systematically searched in May to July 2018 for systematic reviews published after 2013 and for randomised controlled trials (RCTs). A retrospective evaluation of 28 RCTs was performed. Rates of complete wound closure and time to healing were examined for 17 commonly available DSS. Healing rates after 12 weeks and time to complete closure in DFUs are heterogeneous among the 28 RCT. The best healing rates at 12 weeks were accomplished with dermal cellular substitutes (Epifix®, 100% and Amnioband®, 85%) and with dermal acellular substitutes (Allopatch®, 80% and Hyalograft®, 78.8%). Based on these studies, DSS used in conjunction with standard care appear to improve the healing rates of DFUs, as compared with standard care alone. Nonetheless, new studies with more homogeneous samples are needed to ascertain the role of ulcer size, duration, depth and/or type in the efficacy of DSS. Moreover, future RCTs should include patients with severe comorbidities, in order to be more representative of clinical reality.
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Affiliation(s)
- Francisco Javier Álvaro-Afonso
- Diabetic Foot Unit, University Podiatric Clinic, Edificio Facultad de Medicina, Complutense University of Madrid, Instituto de Investigacion Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Yolanda García-Álvarez
- Diabetic Foot Unit, University Podiatric Clinic, Edificio Facultad de Medicina, Complutense University of Madrid, Instituto de Investigacion Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Jose Luis Lázaro-Martínez
- Diabetic Foot Unit, University Podiatric Clinic, Edificio Facultad de Medicina, Complutense University of Madrid, Instituto de Investigacion Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Despoina Kakagia
- Department of Plastic Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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38
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Meloni M, Izzo V, Giurato L, Gandini R, Uccioli L. Management of diabetic persons with foot ulceration during COVID-19 health care emergency: Effectiveness of a new triage pathway. Diabetes Res Clin Pract 2020; 165:108245. [PMID: 32497745 PMCID: PMC7263238 DOI: 10.1016/j.diabres.2020.108245] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/27/2022]
Abstract
AIM To define the outcomes of persons with diabetes and foot ulcers (DFUs) managed through a specific triage pathway during the COVID-19 crisis. METHODS Patients who had an active DFU during the COVID-19 emergency were included. All participants were managed using a specific triage system driven both by ulcer'severity and concomitant co-diseases. Subjects with severely complicated DFUs were urgently referred to hospital regardless of the concomitant comorbidities. Subjects with complicated DFUs received outpatient evaluation (within 48-72 h) and were admitted to hospital if required (revascularization, surgical intervention, intravenous antibiotic therapy); after the first outpatient visit or hospitalization, patients were followed according to the number of comorbidities (in the case of 3 or more comorbidities patients were followed up by telemedicine). Patients with uncomplicated DFUs were managed by telemedicine after outpatient evaluation. Healing, major amputation, death and rate of COVID-19 infection were evaluated. The minimum follow-up was 1 month. RESULTS The study group included 151 patients. The mean age was 69.9 ± 14.2 years, 58.9% were male and 91.4% had type 2 diabetes; 58.7% had severely complicated, 21% complicated and 20.3% uncomplicated DFUs. Among those, 78.8% presented with 3 or more comorbidities. One hundred and six patients had regular clinical follow-ups, while 45 were managed through telemedicine. Forty-one (27.1%) patients healed, 3 (1.9%) had major amputations and 3 (1.9%) died. One patient (0.6%) reported COVID-19 positivity due to infection acquired at home. CONCLUSION The triage pathway adopted during the COVID-19 pandemic showed adequate management of DFUs and no cases of hospital virus exposure.
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Affiliation(s)
- Marco Meloni
- Diabetic Foot Unit, University of Tor Vergata, Rome, Italy.
| | - Valentina Izzo
- Diabetic Foot Unit, University of Tor Vergata, Rome, Italy
| | - Laura Giurato
- Diabetic Foot Unit, University of Tor Vergata, Rome, Italy
| | | | - Luigi Uccioli
- Diabetic Foot Unit, University of Tor Vergata, Rome, Italy
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Bisdas T, Patelis N, Argyrakopoulou G, Tsiachris D, Kurtis A, Gargalianos-Kakoliris P, Stefanadis C. Limb Salvage in Patients With Severe Critical Limb Ischemia (CLI) After Referral for a Second Opinion to a Dedicated CLI Center. INT J LOW EXTR WOUND 2020; 21:174-181. [PMID: 32594790 DOI: 10.1177/1534734620933069] [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: 11/17/2022]
Abstract
The complexity of critical limb ischemia (CLI) requires dedicated multidisciplinary teams of different care providers, who will supervise the full cycle of CLI care. Until CLI treatment is fully centralized, such dedicated teams may work as second-opinion tools before major amputation is undertaken in CLI patients. The aim of the study is to assess the effectiveness of a well-timed referral to a dedicated CLI-center of patients scheduled to major amputation elsewhere. A retrospective analysis of all CLI-patients treated in our department between January 2019 and March 2020 was conducted. Only patients scheduled for a major amputation elsewhere and referred to our clinic were included. Primary endpoint was amputation-free survival, whereas technical success, limb salvage, minor amputation rate, re-admission at 30 days, and frequency of medication change from other disciplines were the secondary endpoints. Sixteen patients with 19 treated limbs were identified and included in this analysis. The WIfI (wound, infection and foot ischemia) clinical stage on admission was 2 in 4 limbs (21%), 3 in 5 limbs (26%), and 4 in 10 limbs (53%). All patients underwent advanced endovascular revascularization. Minor amputation was performed in 8 patients (42%). Amputation-free survival at 6 months was 93% with limb salvage rate of 100%. Technical success and re-admission rates at 30 days was 95% and 6%, respectively. There was a medication adjustment from other specialties in 13 (81%) patients. Patients in severe stages of CLI scheduled to major amputation reached high limb salvage and survival rate, since they are referred for a second opinion to a dedicated multidisciplinary CLI team.
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Manas AB, Taori S, Ahluwalia R, Slim H, Manu C, Rashid H, Kavarthapu V, Edmonds M, Vas PRJ. Admission Time Deep Swab Specimens Compared With Surgical Bone Sampling in Hospitalized Individuals With Diabetic Foot Osteomyelitis and Soft Tissue Infection. INT J LOW EXTR WOUND 2020; 20:300-308. [PMID: 32370639 DOI: 10.1177/1534734620916386] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Whether deep swab cultures taken at admission reliably identify pathogens compared to surgical bone specimens in hospitalized individuals with diabetic foot osteomyelitis and soft tissue infection is unclear. Comparison of microbiological isolates between a deep wound swab (DWS) taken at the time of admission through the actively infected, discharging ulcer probing to the bone and the subsequent surgical bone sample (SBS) taken during surgical debridement was made. A total of 63 subjects (age 60.8 ± 13.5 years, 75% male, 80% Type 2 diabetes, HbA1C 8.9%±2.2%) were included. The proportion of Gram-positive (DWS 49% v SBS 52%) and Gram-negative (DWS 60% v SBS 60%) isolates was similar between the techniques. However, the overall concordance of isolates between the two techniques was only fair (κ=0.302). The best concordance was observed for Staphylococcus aureus (κ=0.571) and MRSA (κ=0.644). There was a correlation between number of isolates in SBS with prior antibiotic therapy of any duration (r= -0.358, p=0.005) and with the duration of ulceration (r=0.296, p=0.045); no clinical correlations were found for DWS. Prior antibiotic therapy (p=0.03) and duration of ulceration <8 weeks (p=0.025) were predictive of negative growth on SBS. In conclusion, we found only a fair concordance between deep wound swabs acquired at admission and surgical bone specimens in those presenting with a severe diabetic foot infection and features of osteomyelitis. Ensuring early surgical debridement of all infected tissue and obtaining bone specimens should be considered a clinical priority, which may also reduce the likelihood of negative growth on SBS.
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Affiliation(s)
| | - Surabhi Taori
- Diabetes Foot Unit, King's College Hospital, London, UK
- School of Immunology & Microbial Sciences, King's College, London, UK
| | | | - Hani Slim
- Diabetes Foot Unit, King's College Hospital, London, UK
| | - C Manu
- Diabetes Foot Unit, King's College Hospital, London, UK
| | - Hisham Rashid
- Diabetes Foot Unit, King's College Hospital, London, UK
| | | | | | - Prashanth R J Vas
- Diabetes Foot Unit, King's College Hospital, London, UK
- Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, UK
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Frykberg RG, Wukich DK, Kavarthapu V, Zgonis T, Dalla Paola L. Surgery for the diabetic foot: A key component of care. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3251. [PMID: 31820543 DOI: 10.1002/dmrr.3251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/21/2019] [Indexed: 12/15/2022]
Abstract
Surgery for acute and chronic diabetic foot problems has long been an integral component of care. While partial foot amputations remain as important diabetic limb-salvaging operations, foot-sparing reconstructive procedures have become equally important strategies to preserve the functional anatomy of the foot while addressing infection, chronic deformities, and ulcerations. A classification of types of diabetic foot surgery is discussed in accordance with the soft tissue status and acuity of the presenting foot problem. This brief overview from the Association for Diabetic Foot Surgeons describes common conditions best treated by surgical interventions, as well as specific indications. While techniques and indications continue to evolve, effective surgical management of the diabetic foot remains an integral component of care as well as for the prevention of recurrent ulceration.
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Uccioli L, Meloni M, Izzo V, Giurato L. Use of Nevelia Dermal-Epidermal Regenerative Template in the Management of Ischemic Diabetic Foot Postsurgical Wounds. INT J LOW EXTR WOUND 2020; 19:282-288. [PMID: 31996064 DOI: 10.1177/1534734619896460] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this cross-sectional study is evaluate the effectiveness of a dermal-epidermal substitute (DES) composed of 3-dimensional porous matrix of type 1, purified, stabilized, bovin-origin collagen (Nevelia, SYMATESE, Chaponost, France) without a subsequent skin graft in the treatment ischemic postsurgical diabetic foot ulcers. This study group was composed of a sample of consecutive diabetic patients with critical limb ischemia and postsurgical wounds. All patients received a preset limb salvage protocol including the application of the DES, but none received a skin graft. Patients were closely followed until wound healing or different outcome. The outcome measures were healing, nonhealing, major amputation, and death evaluated at 1 and 2 years of follow-up. Forty-one patients were included. The average postsurgical wound area was 69.6 ± 50 cm2. Twenty-one patients (51%) healed; 10 patients (24%) did not heal after 1 year of follow-up; however, all of them achieved a mean ulcer size reduction >50%; 7 patients (17%) were amputees; 3 patients (7.3%) died. In a later follow-up (2 years), wounds in 8 additional patients healed. Successful revascularization was an independent predictor of healing (hazard ratio = 5.1, 95% confidence interval [CI] = 2.5-14-9; P = .0001), the postsurgical ulcer size (>50 cm2) was an independent predictor of nonhealing (hazard ratio = 6.2, 95% CI = 2.1-38.4; P = .0001) while recurrence of critical limb ischemia was an independent predictor of major amputation (odds ratio = 3.4, 95% CI = 1.1-4.5; P = .002). The DES composed of type 1 bovin-origin collagen is useful in the treatment of large postsurgical diabetic foot ulcers, even when the skin graft is not a suitable therapeutic option.
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Vas PRJ, Papanas N. Editorial and Mini-Review: Topical Oxygen Therapy for Diabetic Foot Ulcerations - Avenue Towards New Hope? Rev Diabet Stud 2019; 15:71-73. [PMID: 31904758 PMCID: PMC6946091 DOI: 10.1900/rds.2019.15.71] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 12/17/2022] Open
Abstract
Diabetic foot complications now represent the 10th leading cause of disease burden and disability. Wound healing is impaired, leading to chronic ulceration. Local high oxygen concentration is required by the metabolically active cells in the wound, which may render the region hypoxic, even in the absence of peripheral arterial disease. Therefore, the contribution of hyperbaric oxygen to improved healing rates has been extensively investigated. More recent developments include products delivering topical oxygen therapy (TOT) directly at the wound site, either by continuous delivery or by pressurized systems. A very recent systematic review has found that TOT increases wound healing rates in chronic, less severe diabetic foot ulcers (DFUs), and it promotes high rates of healing in more severe ulcers. Thus, TOT appears to be very promising to improve healing in DFUs. We now need more experience regarding its therapeutic place in the algorithm of DFU management and in relation to optimal patient selection.
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Affiliation(s)
- Prashanth RJ Vas
- Diabetic Foot Clinic, King`s College Hospital, London, UK
- Institute of Diabetes, Endocrinology and Obesity, King’s Health Partners, London
| | - Nikolaos Papanas
- Diabetes Centre - Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, G. Kondyli 22c, Alexandroupolis 68100, Greece
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Salutini E, Brocco E, Da Ros R, Monge L, Uccioli L, Anichini R. The Complexity of Diabetic Foot Management: From Common Care to Best Practice. The Italian Expert Opinion by Delphi Survey. INT J LOW EXTR WOUND 2019; 19:34-43. [PMID: 31838925 DOI: 10.1177/1534734619890814] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Diabetic foot is a major public health issue, driven by diabetes complications (neuropathy, peripheral vascular disease, foot deformity, and abnormal leucocyte function), which may lead to leg amputation, thus resulting in severe disability, reduced quality of life, and high health costs. The prevention of diabetes complications and the early detection and proper management of diabetic foot wounds are the milestones to avoid major amputations. Unfortunately, in many areas, the prevention of diabetic foot lesions is inadequate and wounds may proceed toward infection and chronicity, with limb- and life-threatening results. Using the Delphi method, we conducted a survey on diabetic foot among Italian experts, selected across different Italian clinical centers. This method was used to achieve a consensus on current opinion and clinical leanings on the diagnosis and management of diabetic foot ulcers. Specifically, the aim of the survey was to evaluate the current management of the diabetic foot syndrome; highlight the differences in the approach among a group of experts; evaluate the role of wound bed preparation and antisepsis; and discuss any areas of disagreement in which evidences are sparse and the clinical judgment plays a crucial role in the decision-making process.
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Affiliation(s)
| | - Enrico Brocco
- UO per il trattamento del piede diabetico Policlinico Abano Terme, Terme, Italy
| | | | - Luca Monge
- AOU Città della Salute e della Scienza di Torino, SSD Gestione Complicanze del Diabete e Piede Diabetico, Torino, Italy
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Meloni M, Izzo V, Giurato L, Brocco E, Gandini R, Uccioli L. Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers. INT J LOW EXTR WOUND 2019; 19:275-281. [DOI: 10.1177/1534734619884438] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The purpose of this study is to investigate the outcomes of diabetic individuals with ischemic heel ulcers. The study group was composed of a consecutive sample of persons with diabetic ischemic foot ulcers managed by a preset multidisciplinary limb salvage protocol, including revascularization through endovascular technique. The outcome measures were healing, major amputation (above the ankle), and death at 1-year of follow-up. The outcomes between patients with heel ulcers (HUs) and without (NHUs) were compared. A total of 254 patients were recruited. There were 50/254 (19.7%) HUs and 204/254 (79.3%) NHUs. Overall, 190/254 (74.8%) patients healed. The rate of healing for HUs and NHUs was 30/50 (60%) and 160/204 (78.4%); P = .03, respectively. Major amputation occurred in 24/254 (9.4%) patients. The rates of major amputation for HUs and NHUs were 10/50 (20%) and 14/204 (6.9%; P = .002), respectively; 40/254 (15.7%) patients died, unhealed. The rates of mortality for HUs and NHUs were 10/50 (20%) and 30/204 (14.7%; P = .07), respectively. In HUs patients, absence of infection [95% CI = 3.1 (1.6-5.5); P = .002] and superficial ulcers [95% CI = 4.4 (2.2-9.3); P = .0001] were independent predictors of healing, whereas revascularization failure [95% CI = 8.1 (1.5.0-19.4); P = .0001], involvement of the plantar arch [95% CI = 6.3 (2.0-15.4); P = .0001], and dialysis [95% CI = 2.2 (1.3-4.5); P = .006] were independent predictors of major amputation. A multidisciplinary approach achieves good rate of limb salvage in people with diabetic ischemic heel ulcers.
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Abstract
Background Non-removable offloading devices are recommended for the treatment of uncomplicated plantar diabetic foot ulcers because adherence to using removable devices is low. However, patients may not always understand how crucial the non-removability is to ulcer healing, leaving them with the impression that it is the device per se that heals the ulcer. Thus, after ulcer healing when patients return to using removable offloading devices, typically therapeutic footwear, they often return to a low level of adherence resulting in high reulceration rates. To change this pattern of behavior based on a misconception, we need to start with how we as clinicians are conceptualizing treatment with offloading devices. Non-removable offloading devices as commitment devices Commitment devices are voluntary restrictions people put on their future selves to resist short-term temptations and achieve long-term goals. In this paper, it is suggested that a change from viewing non-removable offloading devices as means to force compliance, to viewing them as commitment devices could facilitate a change to a clinical thinking that emphasizes the importance of high adherence without compromising respect for patient autonomy. Conclusion Viewing non-removable offloading devices as commitment devices seems to be a promising approach to emphasize the importance of adherence while respecting patient autonomy. Hopefully, patients’ higher appreciation of the role of adherence can lead to higher adherence to using therapeutic footwear after healing and consequently to reduced reulceration rates.
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Affiliation(s)
- Gustav Jarl
- 1Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, SE 70182 Örebro, Sweden.,2University Health Care Research Center, Faculty of Medicine and Health, Örebro University, SE 70182 Örebro, Sweden
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Lázaro-Martínez JL, Álvaro-Afonso FJ, Sevillano-Fernández D, Molines-Barroso RJ, García-Álvarez Y, García-Morales E. Clinical and Antimicrobial Efficacy of a Silver Foam Dressing With Silicone Adhesive in Diabetic Foot Ulcers With Mild Infection. INT J LOW EXTR WOUND 2019; 18:269-278. [DOI: 10.1177/1534734619866610] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The use of an antimicrobial dressing instead of a non-antimicrobial dressing may increase the number of diabetic foot ulcers healed over a medium-term follow-up period. The study aim was to evaluate the clinical and microbiological efficacy of a silver foam dressing in the management of diabetic foot ulcers. We conducted a single-center, prospective, open, noncontrolled study involving 21 outpatients with diabetic foot ulcers with mild infection. All patients received standard of care for their wounds and a silver foam dressing with silicone adhesive was applied twice per week for wound management during a 6-week treatment period. Soft tissue punch biopsies were taken every second week for qualitative and quantitative microbiological analysis. Wounds were assessed at patient admission, and wound bed tissue was evaluated for presence, quality, and consistency of granulation tissue. Clinical evaluation revealed improvements in wound conditions as a result of treatment with the silver dressing. Wollina wound scores improved significantly, from a mean score of 3.9 ± 1.6 points at inclusion to 6.1 ± 1.3 points at the end of the study (n = 19, P < .001). Treatment with the silver dressing resulted in significant decreases in the bioburden of classically considered diabetic foot ulcer pathogenic organisms such as Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus, Enterobacteriaceae species, Pseudomonas aeruginosa, and other nonfermenting gram-negative bacilli. Findings revealed that the use of silver foam dressing significantly reduced the pathogenic bacterial load and markedly improved the clinical outcome in patients with diabetic foot ulcer with mild infection over a 6-week treatment period.
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Affiliation(s)
- José Luis Lázaro-Martínez
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Francisco Javier Álvaro-Afonso
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - David Sevillano-Fernández
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Raúl Juan Molines-Barroso
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Yolanda García-Álvarez
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Esther García-Morales
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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Ahluwalia R, Vainieri E, Tam J, Sait S, Sinha A, Manu CA, Reichert I, Kavarthapu V, Edmonds M, Vas P. Surgical Diabetic Foot Debridement: Improving Training and Practice Utilizing the Traffic Light Principle. INT J LOW EXTR WOUND 2019; 18:279-286. [PMID: 31237147 DOI: 10.1177/1534734619853657] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Comprehensive management of a severe diabetic foot infection focus on clear treatment pathways. Including rapid, radical debridement of all infection in addition to intravenous antibiotics and supportive measures. However, inexperienced surgeons can often underestimate the extent of infection, risking inadequate debridement, repeated theatre episodes, higher hospital morbidity, and hospital length of stay (LOS). This study aims to assess protocolized diabetic-foot-debridement: Red-Amber-Green (RAG) model as part of a value-based driven intervention. The model highlights necrotic/infected tissue (red-zone, nonviable), followed by areas of moderate damage (amber-zone), healthy tissue (green-zone, viable). Sequential training of orthopedic surgeons supporting our emergency service was undertaken prior to introduction. We compared outcomes before/after RAG introduction (pre-RAG, n = 48; post- RAG, n = 35). Outcomes measured included: impact on number of debridement/individual admission, percentage of individuals requiring multiple debridement, and length-of-hospital-stay as a function-of-cost. All-patients fulfilled grade 2/3, stage-B, of the Texas-Wound-Classification. Those with evidence of ischemia were excluded. The pre-RAG-group were younger (53.8 ± 11.0 years vs 60.3 ± 9.2 years, P = .01); otherwise the 2-groups were matched: HbA1c, white blood cell count, and C-reactive protein. The post-RAG-group underwent significantly lower numbers of debridement's (1.1 ± 0.3 vs 1.5 ± 0.6/individual admission, P = .003); equired fewer visits to theatre (8.6% vs 38%, P = .003), their LOS was reduced (median LOS pre-RAG 36.0 vs post-RAG 21.5 days, P = .02). RAG facilitates infection clearance, fewer theatre-episodes, and shorter LOS. This protocolized-management-tools in acute severely infected diabetic foot infection offers benefits to patients and health-care-gain.
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Molines-Barroso RJ, Lázaro-Martínez JL, Beneit-Montesinos JV, Álvaro-Afonso FJ, García-Morales E, García-Álvarez Y. Early Foot Structural Changes After Lateral Column Exostectomy in Patients With Charcot Foot. INT J LOW EXTR WOUND 2019; 18:129-134. [DOI: 10.1177/1534734619848553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although exostectomy for chronic midfoot plantar ulcers in Charcot foot is apparently effective, with healing rates of nearly 75%, a subset of patients develop recurrent ulceration and show an unstable foot position, especially after undergoing exostectomy confined to the lateral column. The reasons for this failure have not been investigated. The main objective of this study was to evaluate the early changes in radiographic alignment after an exostectomy in patients with Charcot neuropathic osteoarthropathy (rocker bottom) and plantar ulcer located in the lateral column. The present study evaluated retrospectively changes in radiographic alignment after an exostectomy in 12 Charcot feet (rocker bottom) with plantar ulcer located in the lateral column. Indication for plantar exostectomy was the treatment of ulcer affected by osteomyelitis. We evaluated the early changes in the alignment of the foot on weight-bearing lateral radiographs 6 months after exostectomy. Paired sample Wilcoxon test was used to calculate the differences between preoperative and postoperative measurements. Furthermore, the relationship between revision surgery and early changes in radiographic angular measurements was determined by using the Mann-Whitney U test. After exostectomy, the inclination of the calcaneal bone decreased ( P = .003; r = 0.849) and declination of talus bone increased ( P = .041; r = 0.589). The change in calcaneal inclination was associated with revision surgery ( P = .042; r = 0.586). The present case series demonstrates that exostectomy procedure for the lateral column in patients with Charcot foot results in radiological changes in the hindfoot over the sagittal plane. The inversion of the calcaneal pitch angle suggests the possibility of further adverse events and the need for revision surgery.
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Affiliation(s)
- Raúl Juan Molines-Barroso
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - José Luis Lázaro-Martínez
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Juan Vicente Beneit-Montesinos
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Francisco Javier Álvaro-Afonso
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Esther García-Morales
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Yolanda García-Álvarez
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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Zhu C, Yue P, Lü J, Liu X, Huo L, Zhang Z. Treatment of Diabetic Foot Gangrene Using the STAGE Principle: A Case Series. INT J LOW EXTR WOUND 2019; 18:200-207. [PMID: 30968713 DOI: 10.1177/1534734619840584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diabetic foot gangrene with lower extremity ischemia can preclude amputation. However, wound treatment principles based on the Wagner classification system are lacking. We proposed the STAGE principle for the surgical management of diabetic foot wounds. The STAGE principle guides surgical intervention during the wound treatment of diabetic foot ulcers and emphasizes that "based on anatomical layers, the management focuses on blood supply and includes layer-by-layer incision to the infected area, maintenance of effective wound drainage, and step-by-step treatment of the wound." We applied the STAGE principle for the treatment of 7 patients with an ankle brachial index <0.5 and Wagner grade 4 diabetic foot gangrene. The average ankle brachial index was 0.42 (0.32-0.48; SD = 0.06), and male patients smoked an average of 1.28 packs/day (0.4-2; SD = 0.63). The average wound duration was 45.86 days (14-63 days; SD = 18.46). The average wound healing time was 8.86 months (5-13 months; SD = 2.36). The follow-up time was 37.71 months (3-84 months; SD = 25.04; median = 36 months). Patient 1 received endovascular interventional therapy twice for the lower extremity artery, and the wound healed. After 3 months of follow-up, the patient exhibited recurrence. After the third application of endovascular interventional therapy for the lower extremity artery, the blood supply was improved, and the wound healed after 1 month. In summary, the treatment of 7 cases of diabetic foot gangrene with severe lower extremity ischemia using the STAGE principle resulted in remarkable efficacy.
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Affiliation(s)
- Chaojun Zhu
- 1 Second Affiliated Hospital of Tianjin University of TCM, Tianjin, China
| | - Ping Yue
- 2 The First Hospital of Lanzhou University, Lanzhou, China
| | - Jiakang Lü
- 3 Center for Drug Evaluation, National Medical Products Administration, Beijing, China
| | - Xianzhou Liu
- 1 Second Affiliated Hospital of Tianjin University of TCM, Tianjin, China
| | - Lei Huo
- 1 Second Affiliated Hospital of Tianjin University of TCM, Tianjin, China
| | - Zhaohui Zhang
- 1 Second Affiliated Hospital of Tianjin University of TCM, Tianjin, China
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