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Ha Y, Kim JH, Kim J, Kwon H. Non-surgical treatment of diabetic foot ulcers on the dorsum of the foot with polydeoxyribonucleotide injection: Two case reports. World J Clin Cases 2024; 12:4446-4451. [PMID: 39015916 PMCID: PMC11235568 DOI: 10.12998/wjcc.v12.i20.4446] [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: 04/10/2024] [Revised: 05/15/2024] [Accepted: 05/29/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Diabetic foot ulcers are caused by a variety of factors, including peripheral neuropathy, peripheral arterial disease, impaired wound healing mechanisms, and repetitive trauma. Patients with diabetic foot ulcer on the dorsum of the foot are often treated surgically. However, the right non-surgical therapy must be chosen if surgical choices are contraindicated or if the patient prefers conservative treatment over surgery. CASE SUMMARY The purpose of this case report is to highlight the efficacy of polydeoxyribonucleotide (PDRN) injection as a non-surgical treatment option for diabetic foot ulcers on the dorsum of the foot, particularly in patients who choose against surgical intervention. This case report presents two cases of diabetic foot ulcers located on the dorsum of the foot that were successfully treated with PDRN injection as a non-surgical intervention. CONCLUSION If the patient declines surgery for diabetic ulcers with Wagner grade II or below, PDRN injection can be effective if necrotic tissue is removed and the wound bed kept clean.
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Affiliation(s)
- Yooseok Ha
- Department of Plastic and Reconstructive Surgery, Chungnam National University Hospital, Daejeon 35015, South Korea
| | - Jeong-Hee Kim
- Department of Plastic and Reconstructive Surgery, Chungnam National University Hospital, Daejeon 35015, South Korea
| | - Jiyoung Kim
- College of Nursing, Woosuk University, Wanju-gun 55338, South Korea
| | - Hyeokjae Kwon
- Department of Plastic and Reconstructive Surgery, Chungnam National University Hospital, Daejeon 35015, South Korea
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Choi SJ, Lee YH, Kim MB, Bae KJ, Kim S, Lee Y. Reconstruction of Small-Sized Complex Defect on the Foot Dorsum Without Microsurgery: Intrinsic Adipofascial Flap. INT J LOW EXTR WOUND 2023:15347346231154730. [PMID: 36762422 DOI: 10.1177/15347346231154730] [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: 02/11/2023]
Abstract
Dorsal foot defects are difficult to cover and often require major flap surgery by microsurgeons, even for defects of limited sizes. Intrinsic adipofascial flaps for small-sized complex defects are simple and do not require microsurgery; thus, a flap specialist is unnecessary. This study aimed to assess our institutional experience with this technique and define its role in dorsal foot reconstruction. Nine patients aged 48 to 86 years with soft tissue defects of the dorsal foot were treated with the intrinsic adipofascial flap by rotating the adjacent adipofascial tissues from May 2019 and January 2021 in our institution. Demographic, clinical, and followup data were evaluated. Primary outcomes include flap viability, flap bulkiness, ability to wear shoes, and donor site morbidity. The mean followup period was 24.5 months (range, 10-30 months) and the mean defect size was 6.4 cm2 (range, 3.0-9.0 cm2). Eight flaps survived providing an adequate contour and durable coverage with a thin flap. Among 8 cases of healed flaps, 6 required secondary skin grafts while the other 2 healed spontaneously without additional operation. One patient (defect size: 3.0 cm × 3.0 cm) with underlying diabetes mellitus and peripheral arterial occlusive disease encountered flap total necrosis. Revisional flap surgery was performed to cover the flap total necrosis. In conclusion, the intrinsic adipofascial flap is a relatively simple and suitable method for complex dorsal foot defect reconstruction because it provides minimal donor site morbidity. However, relatively large defect size and comorbidities, such as underlying diabetes mellitus and vascular occlusive disease could accompany a risk of flap necrosis.
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Affiliation(s)
- Seong Ju Choi
- Department of Orthopaedic surgery, 46666Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Young Ho Lee
- Department of Orthopaedic surgery, 37990Seoul National University, College of Medicine, Seoul, Korea
| | - Min Bom Kim
- Department of Orthopaedic surgery, 37990Seoul National University, College of Medicine, Seoul, Korea
| | - Kee Jeong Bae
- Department of Orthopaedic surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Segi Kim
- Department of Orthopaedic surgery, 37129CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Yohan Lee
- Department of Orthopaedic surgery, Seoul National University Boramae Medical Center, Seoul, Korea
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Teh J, Sharp R, McKean D. Presurgical Perspective and Postsurgical Evaluation of the Diabetic Foot. Semin Musculoskelet Radiol 2022; 26:717-729. [PMID: 36791740 DOI: 10.1055/s-0042-1760219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Management of the diabetic foot is complex and challenging, requiring a multidisciplinary approach. Imaging plays an important role in the decision-making process regarding surgery. This article discusses the presurgical perspective and postsurgical evaluation of the diabetic foot.
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Affiliation(s)
- James Teh
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Robert Sharp
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - David McKean
- Stoke Mandeville Hospital Buckinghamshire Healthcare NHS Trust
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Yammine K, Eric M, Nasser J, Chahine ASSI. Effectiveness of the Reverse Sural Flap in Covering Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis. Plast Surg (Oakv) 2022; 30:368-377. [PMID: 36212103 PMCID: PMC9537716 DOI: 10.1177/22925503211019617] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/16/2021] [Indexed: 11/03/2023] Open
Abstract
Background: The reverse sural fasciocutaneous flap (RSFCF) has been used with success to cover noncomplicated foot and ankle soft tissue defects. However, there are some controversies when it is used in patients having chronic diabetic foot ulcers. This aim of this meta-analysis was to evaluate the efficacy of RSFCF in covering diabetic foot and ankle ulcers. Methods: A systematic review was undertaken from MEDLINE, EMBASE, Web of Science, Cochrane Library, and Google Scholar. Only diabetic foot and ankle ulcers were accepted for inclusion and all study designs were included. Proximally based flaps, nondiabetic ulcers, and assisted negative pressure therapy were excluded. Suitability for inclusion was assessed by 2 reviewers. The random-effect estimate was reported for the set outcomes whenever high heterogeneity was present. Metaregression analysis was performed to identify independent risk factors for failure. Results: The search identified 33 relevant studies comprising 187 patients and flap interventions; all but 1 were case-series. The weighted outcomes were as follows: (1) the flap healing rate was 93.3% while 6.6% resulted in total necrosis, (2) the rate of partial flap necrosis was 12%, (3) venous congestion was reported in 6.6% of cases, (4) the infection rate was 8.3%, and (5) the donor site morbidity was 4.6%. No association was found between pedicle width or presence of a subcutaneous pedicle tunnel and the primary outcome of total loss. Conclusions: This review demonstrated excellent results of the flap when covering complicated or large diabetic foot and ankle ulcers. When compared to those published in the literature, our results found RSFCF to be relatively less successful in diabetic wounds than in trauma patients but more successful than in those having associated osteomyelitis and those who were treated with random local flaps.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University
Medical Center-Rizk Hospital, Lebanese American University School of Medicine,
Beirut, Lebanon
- Diabetic Foot Clinic, Lebanese American University Medical
Center-Rizk Hospital, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research,
Beirut, Lebanon
| | - Mirela Eric
- Department of Anatomy, University of Novi Sad, Serbia
| | - Jason Nasser
- Lebanese American University School of Medicine, Beirut,
Lebanon
| | - ASSI Chahine
- Department of Orthopedic Surgery, Lebanese American University
Medical Center-Rizk Hospital, Lebanese American University School of Medicine,
Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research,
Beirut, Lebanon
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5
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Evidence-based conservative limb preserving surgery for the diabetic foot complications: A systematic review of systematic reviews. Foot Ankle Surg 2022; 28:670-679. [PMID: 34479784 DOI: 10.1016/j.fas.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/17/2021] [Accepted: 08/21/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Limb preserving surgery for the treatment of diabetic foot complications (DFC) has been shown to yield excellent results and better outcomes when compared to non-surgical standard of care. The quality of the articles reporting the results of limb preserving surgery in treating DFC is quite low. The aim of this study was to evaluate the published systematic reviews and meta-analyses that looked at the efficacy of limb preserving surgery in treating DFC. METHODS PubMed, Cochrane Library and Google Scholar were searched for all systematic reviews and meta-analyses on limb preserving surgery in DFC. The Joanna Briggs Institute (JBI) critical appraisal tool for systematic reviews was used to appraise studies' quality. RESULTS 22 systematic reviews and meta-analyses with a total of 10,559 patients met the inclusion criteria. Five reviews reported on surgical treatment of diabetic Charcot, 5 reviews on bony procedures and 12 reviews on soft tissue procedures for treating DFU. The results of each review were reported. The vast majority of the studies were of Level IV of evidence. The mean JBI score was 9.82. CONCLUSIONS There is an underuse of the available limb preserving operations for the treatment of DFC despite excellent results and variety of procedures available in the literature, especially for Charcot neuroarthropathy and diabetic foot and toe ulcers.
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Yammine K, Assi C. A Systematic Review on the Outcomes of the Fillet Flap in Treating Diabetic and Ischemic Forefoot Ulcers. Plast Surg (Oakv) 2021; 29:178-183. [PMID: 34568233 DOI: 10.1177/2292550320936684] [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] Open
Abstract
Background Diabetic and ischemic foot ulcers are difficult to heal, and the mastering of numerous treatment methods is imperative to achieve healing. One of these methods is the fillet toe flap used to cover specific diabetic wounds of the forefoot associated with toe osteomyelitis. Instead of amputating the infected toe, phalanges are removed while keeping the viable surrounding soft tissue. Methods A systematic review was performed searching electronic databases up to October 2019 to identify relevant articles reporting the outcomes of the fillet flap in forefoot ulcers of patients with diabetes or peripheral artery disease. All study designs were included. The healing rate was the primary outcome. Secondary outcomes were the time to heal, ulcer recurrence, and complication rates of such infection, partial necrosis, and total necrosis. Results The 8 studies that met the inclusion criteria were all case series or case reports, with a total of 28 patients including 29 flaps. The mean healing rate was 92.8% (2/29); in both cases, total necrosis was due to infection (7.2%). No ulcer recurrence or partial necrosis was noted. Conclusions Though having limited indications, the fillet flap illustrates the full optimization of the available resources for wound coverage. The consistent presence of an axial vessel makes the fillet flap a reliable local flap to be used in specific circumstances where the loss of a toe is unavoidable. Further research is needed with large prospective controlled trials to support the findings of the review.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon.,Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon.,Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon.,Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
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Ramanujam CL, Suto AC, Zgonis T. Modification of the abductor digiti minimi muscle flap for soft tissue coverage of the diabetic foot. J Wound Care 2020; 29:S32-S36. [PMID: 32654621 DOI: 10.12968/jowc.2020.29.sup7.s32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The local intrinsic abductor digiti minimi muscle flap is ideal for lateral, plantar lateral traumatic or diabetic foot wounds following adequate surgical debridement to eradicate any soft tissue and/or osseous infection. Although the indications and surgical technique have been well-described in the literature, the authors present a unique modification of tunnelling the harvested muscle flap directly from the donor site to the plantar recipient foot wound by maintaining the intact overlying skin island at the surface of the fifth metatarsal base. This modification allows preservation of the patient's skin integrity in this area, thereby minimising potential morbidity at the major pedicle site. After the harvested muscle is tunnelled through the intact skin island, an adjacent local random flap mobilisation, autogenous or allogeneic skin graft can then be used for coverage over the muscle inset if primary wound closure is not feasible. Simultaneous soft tissue or osseous surgical procedures and/or surgical offloading with external fixation at the time of index surgery may be necessary to achieve optimal outcomes. The authors present a modified surgical technique for the abductor digiti minimi muscle flap that can be performed in the surgical reconstruction of a soft tissue wound in patients with diabetic Charcot neuroarthropathy.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surger, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
| | - Alan C Suto
- LVPG Orthopedics and Sports Medicine, Lehigh Valley Health Network, Bethlehem, Pennsylvania, US
| | - Thomas Zgonis
- Externship and Reconstructive Foot and Ankle Surgery Fellowship Programs, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
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Yin S, Yang X, Bi H, Zhao Z. Combined Use of Autologous Stromal Vascular Fraction Cells and Platelet-Rich Plasma for Chronic Ulceration of the Diabetic Lower Limb Improves Wound Healing. INT J LOW EXTR WOUND 2020; 20:135-142. [PMID: 32131655 DOI: 10.1177/1534734620907978] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The discovery of stromal vascular fraction cells and platelet-rich plasma in promoting tissue regeneration has prompted a new idea for the treatment of chronic diabetic ulcer of the lower limb. The study aim was to evaluate the clinical efficacy of a new method that applied stromal vascular fraction cells and platelet-rich plasma together in the treatment of recalcitrant chronic diabetic ulcer. We conducted a single-center, prospective, open, noncontrolled study. Four patients (5 ulcers in total) who had received standard treatment for diabetic ulcer for at least 3 months that failed to heal was enrolled. All patients were treated with surgical debridement, cell suspension (stromal vascular fraction cells suspended by platelet-rich plasma) injection into the wound, and platelet-rich plasma gel coverage. Wounds were measured every week after treatment using a 2-dimensional digital camera and a 3-dimensional wound measurement device. All patients were followed-up for 4 months after the treatment. Four of the 5 ulcers healed completely within a mean of 71.75 ± 29.57 days. The average proportion of granulation tissue achieved 100% within 4 weeks for all cases. The wound size decreased to less than half of the original size for all cases 4 weeks after the treatment. Findings revealed that the new treatment is efficient to achieve wound healing in patients with recalcitrant chronic diabetic ulcer of lower limb.
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Affiliation(s)
- Shilu Yin
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Xin Yang
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Hongsen Bi
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Zhenmin Zhao
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
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Hasenstein TA, Greene T, Van JC, Meyr AJ. Soft Tissue Reconstruction with Diabetic Foot Tissue Loss. Clin Podiatr Med Surg 2019; 36:425-440. [PMID: 31079608 DOI: 10.1016/j.cpm.2019.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Although substantial advances have been made in treatment of diabetic foot disease with respect to patient education, preventative measures, early intervention, and prophylactic procedures, most surgical interventions for this condition are reactionary. Patients still primarily present to emergency departments with acute infections and tissue necrosis. The surgical intervention for this results in soft tissue deficit, often with partial foot amputation, through excisional debridement of pathologic tissue. Minimizing this initial soft tissue loss, with subsequent reconstruction of the defect, forms the focus of this article with a detailed anatomic assessment of structures at risk in the forefoot, midfoot and rearfoot.
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Affiliation(s)
- Todd A Hasenstein
- Temple University Hospital Podiatric Surgical Residency Program, 8th at Race Street, Philadelphia, PA 19107, USA
| | - Timothy Greene
- Temple University Hospital Podiatric Surgical Residency Program, 8th at Race Street, Philadelphia, PA 19107, USA
| | - Jennifer C Van
- Department of Surgery, Temple University School of Podiatric Medicine, 8th at Race Street, Philadelphia, PA 19107, USA
| | - Andrew J Meyr
- Department of Surgery, Temple University School of Podiatric Medicine, 8th at Race Street, Philadelphia, PA 19107, USA.
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