Diabetic Foot & Ankle最新文献

Objective: Diabetes mellitus (DM) through its over glycosylation of neurovascular structures and resultant peripheral neuropathy continues to be the major risk factor for pedal amputation. Repetitive trauma to the insensate foot results in diabetic foot ulcers, which are at high risk to develop osteomyelitis. Many patients who present with diabetic foot complications will undergo one or more pedal amputations during the course of their disease. The purpose of this study was to determine if obtaining an initial magnetic resonance imaging (MRI), prior to the first amputation, is associated with a decreased rate of reamputation in the diabetic foot. Our hypothesis was that the rate of reamputation may be associated with underutilization of obtaining an initial MRI, useful in presurgical planning. This study was designed to determine whether there was an association between the reamputation rate in diabetic patients and utilization of MRI in the presurgical planning and prior to initial forefoot amputations.

Methods: Following approval by our institutional review board, our study design consisted of a retrospective cohort analysis of 413 patients at Staten Island University Hospital, a 700-bed tertiary referral center between 2008 and 2013 who underwent an initial great toe (hallux) amputation. Of the 413 patients with a hallux amputation, there were 368 eligible patients who had a history of DM with documented hemoglobin A1c (HbA1c) within 3 months of the initial first ray (hallux and first metatarsal) amputation and available radiographic data. Statistical analysis compared the incidence rates of reamputation between patients who underwent initial MRI and those who did not obtain an initial MRI prior to their first amputation. The reamputation rate was compared after adjustment for age, gender, ethnicity, HbA1c, cardiovascular disease, hypoalbuminemia, smoking, body mass index, and prior antibiotic treatment.

Results: The results of our statistical analysis failed to reveal a significant association between obtaining an initial MRI and the reamputation rate. We did, however, find a statistical association between obtaining an early MRI and decreased mortality rates.

Discussion: Obtaining an early MRI was not associated with the reamputation rate incidence in the treatment of the diabetic foot. It did, however, have a statistically significant association with the mortality rate as demonstrated by the increased survival rate in patients undergoing MRI prior to initial amputation.

In the surgical treatment of severe diabetic foot infections, substantial soft tissue loss often accompanies partial foot amputations. These sizeable soft tissue defects require extensive care with the goal of expedited closure to inhibit further infection and to provide resilient surfaces capable of withstanding long-term ambulation. Definitive wound closure management in the diabetic population is dependent on multiple factors and can have a major impact on the risk of future diabetic foot complications. In this article, the authors provide an overview of autogenous skin grafting, including anatomical considerations, clinical conditions, surgical approach, and adjunctive treatments, for diabetic partial foot amputations.

Background: Intralesional recombinant epidermal growth factor (EGF) was produced in the Centre for Genetic Engineering and Biotechnology (CIGB), Cuba, in 1988 and licensed in 2006. Because it may accelerate wound healing, it is a potential new treatment option in patients with a diabetic foot wound (whether infected or not) as an adjunct to standard treatment (i.e. debridement, antibiotics). We conducted the initial evaluation of EGF for diabetic foot wounds in Turkey.

Methods: We enrolled 17 patients who were hospitalized in various medical centers for a foot ulcer and/or infection and for whom below the knee amputation was suggested to all except one. All patients received 75 μg intralesional EGF three times per week on alternate days.

Results: The appearance of new granulation tissue on the wound site (≥75%) was observed in 13 patients (76%), and complete wound closure was observed in 3 patients (18%), yielding a 'complete recovery' rate of 94%. The most common side effects were tremor (n=10, 59%) and nausea (n=6, 35%). In only one case,a serious side effect requiring cessation of EGF treatment was noted. That patient experienced severe hypotension at the 16th application session, and treatment was discontinued. At baseline, a total of 21 causative bacteria were isolated from 15 patients, whereascultures were sterile in two patients. The most frequently isolated species was Pseudomonas aeruginosa.

Conclusion: Thus, this preliminary study suggests that EGF seems to be a potential adjunctive treatment option in patients with limb-threatening diabetic foot wounds.

Retrograde tibiopedal approach is being used frequently in below-the-knee vascular interventions. In patients with diabetic foot pathology, complex anatomy often requires a retrograde technique when the distal vascular anatomy and puncture site is suitable. The dorsalis pedis and posterior tibial arteries can be punctured because of their relatively superficial position. We report a retrograde puncturing technique in patients with chronic total occlusions. After failed antegrade recanalization, puncturing and cannulation of a tiny dorsalis pedis artery with a narrow bore [20-gauge (0.8 mm)] intravenous cannula is described.

Negative-pressure wound therapy (NPWT) plays an important role in the treatment of complex wounds. Its effect on limb salvage in the management of the diabetic foot is well described in the literature. However, a successful outcome in this subgroup of diabetic patients requires a multidisciplinary approach with careful patient selection, appropriate surgical debridement, targeted antibiotic therapy, and optimization of healing markers. Evolving NPWT technology including instillation therapy, nanocrystalline adjuncts, and portable systems can further improve results if used with correct indications. This review article summarizes current knowledge about the role of NPWT in the management of the diabetic foot and its mode of action, clinical applications, and recent developments.

Objective: The purpose of this study was to evaluate the impact of the employment of additional podiatry staff on patients with diabetes attending a community-based podiatry service.

Methods: An audit was conducted to evaluate the intervention of two additional podiatry staff. All patients with diabetes referred to and attending community podiatry services in a specified area in the Republic of Ireland between June 2011 and June 2012 were included. The service was benchmarked against the UK gold standard outlined in the 'Guidelines on prevention & management of foot problems in Type 2 Diabetes' by the National Institute of Clinical Excellence (NICE). Process of care measures addressed were the number of patients with diabetes receiving treatment and the waiting times of patients with diabetes from referral to initial review.

Results: An increase in the number of patients with diabetes receiving treatment was seen in all risk categories (ranging from low risk to the emergency foot). Waiting times for patients with diabetes decreased post-intervention but did not reach the targets outlined in the NICE guidelines. The average time from referral to initial review of patients with an emergency diabetic foot was 37 weeks post-intervention. NICE guidelines recommend that these patients are seen within 24 hours.

Discussion: During the life cycle of this audit, increased numbers of patients were treated and waiting times for patients with diabetes were reduced. An internal re-organisation of the services coincided with the commencement of the additional staff. The improvements observed were due to the effects of a combination of additional staff and service re-organisation. Efficient organisation of services is key to optimal performance. Continued efforts to improve services are required to reach the standards outlined in the NICE guidelines.