Diabetic Foot & Ankle最新文献

Background: The management of chronic diabetic foot ulcers (DFU) poses a great challenge to the treating physician and surgeon. The aim of this study was to identify the risk factors, clinical presentation, and outcomes associated with chronic DFU>6 months' duration.

Methods: This prospective study was performed in Jabir Abu Eliz Diabetic Centre (JADC), Khartoum, Sudan. A total of 108 patients who had DFU for >6 months were included. Recorded data included patient's demographics, DFU presentation, associated comorbidities, and outcomes. DFU description included size, depth, protective sensation, perfusion, and presence of infection. Comorbidities assessed included eye impairment, renal and heart disease. All patients received necessary local wound care with sharp debridement of any concomitant necrotic and infected tissues and off-loading with appropriate shoe gear and therapeutic devices.

Results: The mean age of the studied patients was 56+SD 9 years with a male to female ratio of 3:3.3. The mean duration of DFU was 18±SD 17 months (ranging from 6 to 84 months). Ulcer healing was significantly associated with off-loading, mainly the use of total contact cast (TCC) (p=0.013). Non-healing ulcerations were significantly associated with longer duration of the chronic DFU>12 months (p=0.002), smoking (p=0.000), poor glycemic control as evidenced by an elevated HbA1c (>7%), large size (mean SD 8+4 cm), increased depth (p<0.001), presence of skin callus (p<0.000), impaired limb perfusion (p=0.001), impaired protective sensation as measured by 10 g monofilament (p=0.002), neuroischemia (p=0.002), and Charcot neuroarthropathy (p=0.017).

Discussion: Risk factors associated with chronic DFU of>6 months' duration included the presentation of an ulcer with increased size and depth, with associated skin callus and neuroischemia, in a diabetic patient with a history of smoking and increased HbA1c >7%. Off-loading mainly with the use of TCC is an effective method of managing long-standing DFU.

Background: The aim of this study was to determine the incidence of complications associated with primary closure in surgical procedures performed for diabetic foot osteomyelitis compared to those healed by secondary intention. In addition, further evaluation of the surgical digital debridement for osteomyelitis with primary closure as an alternative to patients with digital amputation was also examined in our study.

Methods: Comparative study that included 46 patients with diabetic foot ulcerations. Surgical debridement of the infected bone was performed on all patients. Depending on the surgical technique used, primary surgical closure was performed on 34 patients (73.9%, Group 1) while the rest of the 12 patients were allowed to heal by secondary intention (26.1%, Group 2). During surgical intervention, bone samples were collected for both microbiological and histopathological analyses. Post-surgical complications were recorded in both groups during the recovery period.

Results: The average healing time was 9.9±SD 8.4 weeks in Group 1 and 19.1±SD 16.9 weeks in Group 2 (p=0.008). The percentage of complications was 61.8% in Group 1 and 58.3% in Group 2 (p=0.834). In all patients with digital ulcerations that were necessary for an amputation, a primary surgical closure was performed with successful outcomes.

Discussion: Primary surgical closure was not associated with a greater number of complications. Patients who received primary surgical closure had faster healing rates and experienced a lower percentage of exudation (p=0.05), edema (p<0.001) and reinfection, factors that determine the delay in wound healing and affect the prognosis of the surgical outcome. Further research with a greater number of patients is required to better define the cases for which primary surgical closure may be indicated at different levels of the diabetic foot.

We retrospectively reviewed 107 diabetic patients who received a split thickness skin graft (STSG) for treatment of a non-healing diabetic foot or leg ulcer to describe healing times based on patient characteristics, comorbidities or complications. The minimum follow-up was 6 months from the time of STSG application. The mean time to healing among all patients was 5.1 weeks (3 to 16 weeks). The mean healing time for patients with complications was 12.0 weeks (10 to 16 weeks) while the mean healing time for those without complications was 4.9 weeks (3 to 10 weeks). Overall complication rate was 2.8%. Patients with a STSG take of less than 95% had a mean healing time of 7.9 weeks compared to 4.8 weeks for those with a STSG take of 100% (p<0.001). The use of autologous STSG for treatment of non-healing diabetic foot and leg wounds is a viable method for soft tissue closure and may present a low complication rate and a satisfactory rate of healing.

A diabetic foot infection is usually the result of a pre-existing foot ulceration and is the leading cause of lower extremity amputation in patients with diabetes. It is widely accepted that diabetic foot infections may be challenging to treat for several reasons. The devastating effects of hyperglycemia on host defense, ischemia, multi-drug resistant bacteria and spreading of infection through the foot may complicate the course of diabetic foot infections. Understanding the ways in which infections spread through the diabetic foot is a pivotal factor in order to decide the best approach for the patient's treatment. The ways in which infections spread can be explained by the anatomical division of the foot into compartments, the tendons included in the compartments, the initial location of the point of entry of the infection and the type of infection that the patient has. The aim of this paper is to further comment on the existed and proposed anatomical principles of the spread of infection through the foot in patients with diabetes.

Diabetic foot ulcers (DFU) are one of the most important complications in people with diabetes mellitus. The present study was aimed to retrospectively review the efficacy of at least 1-week medical treatment before any surgical intervention in patients with Grade-3 and higher DFU according to Wagner's classification. A total of 52 patients (36 males and 16 females) hospitalized and treated between June 2006 and February 2009 and had initially received therapeutic treatment (local wound care, antibiotic therapy and blood glucose regulation) for a period of at least 1 week were included in the study. The level of amputation, rates of reulceration and mortality in both groups were recorded in the following period of 2 years. Group 1 (did not respond to preoperative medical intervention) included 16 patients where a surgical debridement, flap or skin graft surgery was performed in 2 (12.5%) patients, major amputation was performed in another 2 (12.5%) patients and minor amputation was performed in the remaining 12 (75%) patients. Of 36 patients in Group 2 (did respond to preoperative medical intervention), 5 (13.9%) patients underwent the surgical debridement, flap or skin graft surgery, 8 (22.2%) patients had a major amputation and the remaining 23 (63.9%) patients lead to a minor amputation. The ulcer recurrence and mortality rates were obtained as 2 (12.5%) and 2 (12.5%) in Group 1 and 2 (5.6%) and 1 (2.8%) in Group 2, respectively. Despite the lower rates of ulcer recurrence and mortality in patients having adequate responses to initial treatment before surgical procedures were performed, no statistically significant difference was observed between the 2 groups. In addition, there was no statistically significant difference between the levels of amputation in both groups.

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.

Diabetic foot infections are a high risk for lower extremity amputation in patients with dense peripheral neuropathy and/or peripheral vascular disease. When they present with concomitant osteomyelitis, it poses a great challenge to the surgical and medical teams with continuing debates regarding the treatment strategy. A cohort prospective study conducted between October 2005 and October 2010 included 330 diabetic patients with osteomyelitis mainly involving the forefoot (study group) and 1,808 patients without foot osteomyelitis (control group). Diagnosis of osteomyelitis was based on probing to bone test with bone cultures for microbiological studies and/or repeated plain radiographic findings. Surgical treatment included debridement, sequestrectomy, resections of metatarsal and digital bones, or toe amputation. Antibiotics were started as empirical and modified according to the final culture and sensitivities for all patients. Patients were followed for at least 1 year after wound healing. The mean age of the study group was 56.7 years (SD = 11.4) compared to the control group of 56.3 years (SD = 12.1), while the male to female ratio was 3:1. At initial presentation, 82.1% (n=271) of the study group had an ulcer penetrating the bone or joint level. The most common pathogens were Staphylococcus aureus (33.3%), Pseudomonas aeruginosa (32.2%), and Escherichia coli (22.2%) with an almost similar pattern in the control group. In the study group, wound healing occurred in less than 6 months in 73% of patients compared to 89.9% in the control group. In the study group, 52 patients (15.8%) had a major lower extremity amputation versus 61 in the control group (3.4%) (P=0.001). During the postoperative follow-up visits, 12.1% of patients in each group developed wound recurrence. In conclusion, combined surgical and medical treatment for diabetic foot osteomyelitis can achieve acceptable limb salvage rate and also reduce the duration of time to healing along with the duration of antibiotic treatment and wound recurrence rate.

Background: A diabetic foot or lower extremity amputation may be exacerbated by or related to the smoking habits and history of the patient.

Patients and methods: Of the 112 diabetic patients in this retrospective study, 46 were non-smokers and 66 were smokers. The smokers were further categorized into patients who: 1) did not cease smoking; 2) ceased in the immediate post-operative period but resumed within 3 months; and 3) ceased up to and at the 3-month post-operative period. The patients were also divided by their amputation level of forefoot, midfoot/rearfoot, and proximal leg.

Results: Smoking diabetic patients underwent more amputations, as well as more proximal amputations than those who did not smoke. The higher amount of smoking in pack years followed an increasing trend of more proximal amputations as well.

Conclusion: Neither the amputation level nor the amputation itself was enough motivation for the patients to participate in smoking cessation.