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Mokoala TC, Sididzha V, Molefe ED, Luvhengo TE. Life expectancy of patients with diabetic foot sepsis post-lower extremity amputation at a regional hospital in a South African setting. A retrospective cohort study. Surgeon 2024; 22:e109-e114. [PMID: 38101992 DOI: 10.1016/j.surge.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Diabetes foot sepsis (DFS) is the leading cause of amputation of lower extremities. Over 50 % of patients who have had major lower extremity amputation due to DFS are dead within 4 years following the procedure. AIM To determine the life expectancy of patients following amputation for DFS at a regional hospital in South Africa. METHODS We conducted an audit of patients who had DFS and were admitted over a 5-year period. The duration from admission to time of death was recorded in days. Occurrence of death was confirmed from family members of the deceased using structured telephonic interview questionnaires. Categorical findings were summarized using actual counts and percentages and compared using either the Chi-square or Fisher's exact test. We used the mean with standard deviation or median and range to compare parametric and non-parametric continuous data, respectively. The Shapiro-Wilk test was used to test normality of data. Multivariate logistic regression was done to establish factors that were strongly associated with the mortalities. Adjusted survival curves were added to compare the rate of occurrence of mortality between males and females with age as a confounder. Statistical significance was set at a p-value below 0.05. RESULTS 197 were found of which 100 % of participants had Type 2 diabetes mellitus and 63.5 % were males. Associated comorbidities included hypertension in 73.6 %, obesity in 66 %, alcohol use in 64.5 % and smoking in 58.4 %. 190 participants had an amputation and 19.3 % died. CONCLUSION DFS was more common in males and 96 % of the patients had an amputation. Mortality rate within 4 years following amputation was 19.3 % and was higher in females and individuals with multiple comorbidities.
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Godoy-Santos AL, Fonseca FC, de Cesar-Netto C, Bang K, Pires EA, Armstrong DG. Staged salvage of diabetic foot with Chopart amputation and intramedullary nailing. SAGE Open Med Case Rep 2021; 9:2050313X211046732. [PMID: 34552752 PMCID: PMC8450981 DOI: 10.1177/2050313x211046732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/30/2021] [Indexed: 11/22/2022] Open
Abstract
We present a stepwise surgical approach that can be used, in lieu of a transtibial amputation, to preserve the lower limb in the setting of severe diabetic foot infections. A 63-year-old male status post left midfoot (Lisfranc’s) amputation presented to our hospital with a 4-year history of a left foot diabetic ulcer with associated purulent drainage and intermittent chills. On initial exam, the patient’s left foot amputation stump was plantarflexed, grossly erythematous, and edematous. The associated diabetic foot ulcer was actively draining purulent fluid. Following workup with radiography and ultrasound, the patient was diagnosed with a post-operative infection of the midfoot at the level of the amputation stump secondary to diabetic neuropathy. Our approach to management was a staged and included (1) surgical irrigation and debridement of the distal stump wound, (2) provisional negative pressure therapy, (3) a second-look procedure, and (4) a tibiotalocalcaneal fusion was performed using a lateral transfibular and plantar approach, after wound closure and resolution of active infection was achieved. At 36-month follow-up, the patient was fully weight-bearing in stiff sole sneakers with no gross overt alteration of gait pattern. The patient scored 79 points when assessed by the hindfoot American Orthopaedic Foot and Ankle Society Ankle-Hindfoot outcome score. In the patient with diabetes and cardiological restrictions, a Chopart amputation is preferred due to the decreased level of energy expenditure required for ambulation as compared to over more proximal levels of amputation.
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Affiliation(s)
- Alexandre Leme Godoy-Santos
- Department of Orthopedic Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Lab. Prof Manlio Mario Marco Napoli, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fábio Correa Fonseca
- Lab. Prof Manlio Mario Marco Napoli, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Cesar de Cesar-Netto
- Department of Orthopedics and Rehabilitation, The University of Iowa, Iowa City, IA, USA
| | - Katrina Bang
- Department of Orthopedics and Rehabilitation, The University of Iowa, Iowa City, IA, USA
- School of Medicine, St. George’s University, St. George’s, Grenada
| | - Eduardo Araujo Pires
- Department of Orthopedic Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Eduardo Araujo Pires, Department of Orthopedic Surgery, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, Morumbi, São Paulo, SP 05652-900, Brazil.
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Khan T, Plotkin A, Magee GA, Shin L, Woelfel SL, Ziegler KR, Shih CD, Weaver FA, Armstrong DG, Rowe VL. Functional ambulatory status as a potential adjunctive decision-making tool following wound, level of ischemia, and severity of foot infection assessment. J Vasc Surg 2020; 72:738-746. [PMID: 32273222 DOI: 10.1016/j.jvs.2019.11.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 11/12/2019] [Indexed: 11/26/2022]
Abstract
The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System has been developed to stratify amputation risk on the basis of extent of the wound, level of ischemia, and severity of foot infection (WIfI). However, there are no currently validated metrics to assess, grade, and consider functional status, especially ambulatory status, as a major consideration during limb salvage efforts. Therefore, we propose an adjunct to the current WIfI system to include the patient's ambulatory functional status after initial assessment of limb threat. We propose a functional ambulatory score divided into grade 0, ambulation outside the home with or without an assistive device; grade 1, ambulation within the home with or without an assistive device; grade 2, minimal ambulation, limbs used for transfers; and grade 3, a person who is bed-bound. Adding ambulatory function as a supplementary assessment tool can guide clinical decision making to achieve optimal future functional ambulatory outcome, a patient-centered goal as critical as limb preservation. This adjunct may aid limb preservation teams in rapid, effective communication and clinical decision making after initial WIfI assessment. It may also improve efforts toward patient-centered care and functional ambulatory outcome as a primary objective. We suggest a score of functional ambulatory status should be included in future trials of patients with chronic limb-threatening ischemia.
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Affiliation(s)
- Tanzim Khan
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Anastasia Plotkin
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Laura Shin
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Stephanie L Woelfel
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Kenneth R Ziegler
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Chia Ding Shih
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - David G Armstrong
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Vincent L Rowe
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif.
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Godoy-Santos AL, Rosemberg LA, de Cesar-Netto C, Armstrong DG. The use of bioactive glass S53P4 in the treatment of an infected Charcot foot: a case report. J Wound Care 2019; 28:S14-S17. [PMID: 30724119 DOI: 10.12968/jowc.2019.28.sup1.s14] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE: To report a case of successful limb-salvage staged treatment in the treatment of an infected diabetic Charcot foot. CASE SUMMARY: A 45-year-old male with long-term, uncontrolled type 2 diabetes, six months' history of progressive deformity on the right foot and 45 days of purulent drainage in the lateral aspect of the foot. Patient was diagnosed with an infected Charcot foot with extensive midfoot bone involvement as shown by radiographic and MRI images. We used a multidisciplinary approach to treatment with early antibiotic therapy, tight glycaemic control and staged surgical treatment. Initial treatment was adequate irrigation and debridement, bone-void filling with bioactive glass, external fixation and provisional negative pressure wound therapy (NPWT). Later progressed to total contact casting and progressive protect weight bearing. At final follow-up, patient was full weight-bearing in stiff soled footwear, with no clinical signs of infection, no gross alteration of gait pattern and demonstrating complete bone healing and integration of the bioactive glass. CONCLUSION: The bioactive glass S53P4 was successfully used in the limb-salvage staged treatment of a patient with an infected Charcot foot. Here, full integration with the surrounding bone and its supportive action in the combat of bone infection was demonstrated.
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Affiliation(s)
- Alexandre L Godoy-Santos
- Department of Orthopedic Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, BR; and Departamento de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Laercio A Rosemberg
- Departamento de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil; and Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Cesar de Cesar-Netto
- Fellow of Department of Orthopedics Foot and Ankle, Hospital for Special Surgery, New York, NY, US
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, US
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Parenti J. Functional ambulation without lower-leg muscles or nerves - a case report with video. Acta Orthop 2019; 90:622-623. [PMID: 31315461 PMCID: PMC6844399 DOI: 10.1080/17453674.2019.1642432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- John Parenti
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA,Correspondence:
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van Netten JJ, Seng L, Lazzarini PA, Warnock J, Ploderer B. Reasons for (non-)adherence to self-care in people with a diabetic foot ulcer. Wound Repair Regen 2019; 27:530-539. [PMID: 31107578 DOI: 10.1111/wrr.12728] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 05/14/2019] [Indexed: 12/20/2022]
Abstract
We aimed to explore reasons for (non-)adherence to self-care among people with diabetic foot ulcers, as well as barriers and solutions to improving their self-care adherence. We performed a qualitative study, recruiting people with a diabetic foot ulcer from a community diabetic foot clinic. Semistructured interviews were held with participants. Data saturation occurred after 9 and was confirmed after 11 participant interviews. Interviews were audio-taped, transcribed verbatim and analyzed using the framework approach. Findings were mapped and the World Health Organization's (WHO) adherence dimensions were applied to themes identified. The key themes identified were (1) participants performed recommended practices in self-care; (2) participants relied heavily on care support; (3) motivations for self-care came from "staying well"; and (4) there was a disparity between self-care knowledge and understanding. Barriers identified included poor mobility and visibility, difficulty wearing offloading devices or using wound dressings, and frustration with lack of progress. Solutions to improve adherence included integrating self-care as routine, improved education, more external help and improving visibility. All five WHO adherence dimensions played a role in (non-)adherence to diabetic foot ulcer self-care. We conclude that adherence to recommended diabetic foot ulcer self-care was limited at best, and reasons for nonadherence were multidimensional. Based on the factors related to (non-)adherence and the barriers and solutions described, we suggest clinicians obtain a broad view of a person's situation when aiming to improve self-care adherence.
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Affiliation(s)
- Jaap J van Netten
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia.,Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Department of surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
| | - Leonard Seng
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Peter A Lazzarini
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia.,Allied Health Research Collaborative, Metro North Hospital and Health Service, The Prince Charles Hospital, Brisbane, Australia
| | - Jason Warnock
- Podiatry Service, Metro North Hospital and Health Service, The Prince Charles Hospital, Brisbane, Australia
| | - Bernd Ploderer
- School of Electrical Engineering and Computer Science, Queensland University of Technology, Brisbane, Australia
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Godoy-Santos AL, Amodio DT, Pires A, Lima ALM, Wei TH, de Cesar-Netto C, Armstrong DG. Diabetic limb salvage procedure with bone allograft and free flap transfer: a case report. Diabet Foot Ankle 2017; 8:1270076. [PMID: 28326158 PMCID: PMC5328323 DOI: 10.1080/2000625x.2016.1270076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/27/2016] [Accepted: 11/28/2016] [Indexed: 11/23/2022]
Abstract
The aim of this case report was to describe a successful diabetic limb salvage procedure in the treatment of an infected diabetic foot ulcer through a multidisciplinary team approach and complex surgical reconstruction involving a femoral head bone allograft and musculocutaneous latissimus dorsi free flap. The decision to proceed with aggressive staged efforts at diabetic limb salvage should be made only after careful consultation with the patient, his or her family, and the rest of the multidisciplinary healthcare team.
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Affiliation(s)
| | - Daniel T Amodio
- Department of Orthopedic Surgery, Hospital do Coraçao , São Paulo , Brazil
| | - André Pires
- Department of Orthopedic Surgery, University of São Paulo , São Paulo , Brazil
| | - Ana L M Lima
- Department of Orthopedic Surgery, University of São Paulo , São Paulo , Brazil
| | - Teng H Wei
- Department of Orthopedic Surgery, University of São Paulo , São Paulo , Brazil
| | - Cesar de Cesar-Netto
- Department of Orthopedic Surgery, Medstar Union Memorial Hospital , Baltimore , MD , USA
| | - David G Armstrong
- Department of Surgery, The University of Arizona , Tucson , AZ , USA
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van Netten JJ, Fortington LV, Hinchliffe RJ, Hijmans JM. Early Post-operative Mortality After Major Lower Limb Amputation: A Systematic Review of Population and Regional Based Studies. Eur J Vasc Endovasc Surg 2015; 51:248-57. [PMID: 26588994 DOI: 10.1016/j.ejvs.2015.10.001] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 10/02/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Lower limb amputation is often associated with a high risk of early post-operative mortality. Mortality rates are also increasingly being put forward as a possible benchmark for surgical performance. The primary aim of this systematic review is to investigate early post-operative mortality following a major lower limb amputation in population/regional based studies, and reported factors that might influence these mortality outcomes. METHODS Embase, PubMed, Cinahl and Psycinfo were searched for publications in any language on 30 day or in hospital mortality after major lower limb amputation in population/regional based studies. PRISMA guidelines were followed. A self developed checklist was used to assess quality and susceptibility to bias. Summary data were extracted for the percentage of the population who died; pooling of quantitative results was not possible because of methodological differences between studies. RESULTS Of the 9,082 publications identified, results were included from 21. The percentage of the population undergoing amputation who died within 30 days ranged from 7% to 22%, the in hospital equivalent was 4-20%. Transfemoral amputation and older age were found to have a higher proportion of early post-operative mortality, compared with transtibial and younger age, respectively. Other patient factors or surgical treatment choices related to increased early post-operative mortality varied between studies. CONCLUSIONS Early post-operative mortality rates vary from 4% to 22%. There are very limited data presented for patient related factors (age, comorbidities) that influence mortality. Even less is known about factors related to surgical treatment choices, being limited to amputation level. More information is needed to allow comparison across studies or for any benchmarking of acceptable mortality rates. Agreement is needed on key factors to be reported.
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Affiliation(s)
- J J van Netten
- Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands.
| | - L V Fortington
- Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Australia
| | - R J Hinchliffe
- St. George's Vascular Institute, St. George's Healthcare NHS Trust, London, UK
| | - J M Hijmans
- University of Groningen, University Medical Center, Department of Rehabilitation Medicine, Groningen, The Netherlands
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Miller JD, Salloum M, Button A, Giovinco NA, Armstrong DG. How Can I Maintain My Patient With Diabetes and History of Foot Ulcer in Remission? INT J LOW EXTR WOUND 2014; 13:371-7. [DOI: 10.1177/1534734614545874] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Patients with diabetes and previous history of ulceration occupy the highest category of risk for reulceration and amputation. Annual recurrence rates of diabetic ulcerations have been reported as high as 34%, 61%, and 70% at 1, 3, and 5 years, respectively, with studies reporting 20% to 58% recurrence rate within 1 year. As the ever growing epidemic of diabetes expands globally, this sequelae of diabetic complication will continue to require increasing resources from the healthcare community to effectively manage. Recent data suggest that removal of preventative podiatric care from statewide reimbursement systems lead to significant and sustained increases in hospital admission (37%), charges (38%), length of stay (23%), and severe aggregate outcomes including amputation, sepsis and death (49%). The addition of comorbidities such as peripheral artery disease, poor nutrition, and non-adherence to preventive therapies not only increase a patient’s likelihood for ulcer recurrence, but also cost of care and certainty of hospital admission. Currently, numerous efforts, guidelines, and industry generated products exist to prolong remission from ulceration; however, the clinical science for treating this patient population calls for much more effort. Despite this, data continue to suggest to demonstrate that appropriate follow-up care, shoe and insole modification, and patient education play a central role in reducing reulceration and amputation. Novel modalities for offloading and wearable sensor technologies offer the advantage of round-the-clock, patient specific and active response healthcare. These have the potential to detect, or even prevent, many wounds before they begin.
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Affiliation(s)
- John D. Miller
- Des Moines University College of Podiatric Medicine, Des Moines, IA, USA
| | | | - Alex Button
- Midwestern College of Podiatric Medicine, Glendale, AZ, USA
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Fiorito J, Trinidad-Hernadez M, Leykum B, Smith D, Mills JL, Armstrong DG. A tale of two soles: sociomechanical and biomechanical considerations in diabetic limb salvage and amputation decision-making in the worst of times. Diabet Foot Ankle 2012; 3:18633. [PMID: 23050063 PMCID: PMC3464045 DOI: 10.3402/dfa.v3i0.18633] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Foot ulcerations complicated by infection are the major cause of limb loss in people with diabetes. This is especially true in those patients with severe sepsis. Determining whether to amputate or attempt to salvage a limb often requires in depth evaluation of each individual patient's physical, mental, and socioeconomic status. The current report presents and juxtaposes two similar patients, admitted to the same service at the same time with severe diabetic foot infections complicated by sepsis. We describe in detail the similarities and differences in the clinical presentation, extent of infection, etiology, and socioeconomic concerns that ultimately led to divergent clinical decisions regarding the choices of attempting diabetic limb salvage versus primary amputation and prompt rehabilitation.
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Affiliation(s)
- Joseph Fiorito
- Southern Arizona Limb Salvage Alliance (SALSA), Division of Vascular and Endovascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
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