Does a shorter residual first metatarsal length after first ray amputation in diabetic patients leads to poorer outcomes - A risk factor study

Early Outcomes and Complications of Surgically Treated Diabetic Hallucal Infection

BACKGROUND

Severely infected diabetic ulcers of the big toe often necessitate surgical treatment. Depending on the wound stage and presence of osteomyelitis, conservative surgery and amputation are the main surgical treatments. Few articles reported the outcomes and complications of such procedures. This study is a preliminary comparative report on the early outcomes and complications of hallucal diabetic foot infection (DFI) treated with either conservative surgery or amputation.

METHODS

This is a retrospective comparative study comprising a continuous series of patients admitted at our hospital. Initially, all diabetic foot ulcer (DFU) were infected and at advanced stage (Wagner Grade 3 or 4). All clinically suspected cases of osteomyelitis were confirmed by bone pathology and microbiology culture. The study included 37 patients diagnosed with DFI. Infection profile was as follows: 23 DFU with osteomyelitis (Wagner Grade 3 or 4) and 14 infected DFU (Wagner Grade 2). Twenty-four conservative procedures and 13 amputation surgeries were performed initially. The primary outcome was defined as the frequency of subsequent surgery (deep infection recurrence treated with surgery). Statistical analysis was used to look for significant difference between both groups.

RESULTS

Ten patients (27%) required additional surgeries because of deep infection recurrence. Four recurrences (16.7%) were observed in the conservative group and 6 (46%) in the amputation group (P = 0.054). Amputation rate as a subsequent procedure was 8.3% for the conservative group and the reamputation rate for the amputation group was 23.1% (P = 0.2).

CONCLUSIONS

The study findings would indicate that the more severe is the initial hallucal infection severity (higher Wagner grade), the higher is the frequency of early surgical complications mainly after an index amputation procedure. Our assessment tools of initial infection extent seem to be underperforming. A more aggressive treatment in the form of a more proximal cut with regard to magnetic resonance imaging bone infection signal could be considered to minimize the risk of subsequent surgeries and reamputations.

A Multifunctional Hydrogel Fabricated by Direct Self-Assembly of Natural Herbal Small Molecule Mangiferin for Treating Diabetic Wounds

Clinical studies have continually referred to the involvement of drug carrier having dramatic negative influences on the biocompatibility, biodegradability, and loading efficacy of hydrogel. To overcome this deficiency, researchers have proposed to directly self-assemble natural herbal small molecules into a hydrogel without any structural modification. However, it is still a formidable challenge due to the high requirements on the structure of natural molecules, leading to a rarity of this type of hydrogel. Mangiferin (MF) is a natural polyphenol of C-glucoside xanthone with various positive health benefits, including the treatment of diabetic wounds, but its poor hydrosolubility and low bioavailability significantly restrict the clinical application. Inspired by these, with heating/cooling treatment, a carrier-free hydrogel (MF-gel) is developed by assembling the natural herbal molecule mangiferin, which is mainly governed through hydrogen bonds and intermolecular π-π stacking interactions. The as-prepared hydrogel has injectable and self-healing properties and shows excellent biocompatibility, continuous release ability, and reversible stimuli-responsive performances. All of the superiorities enable the MF-based hydrogel to serve as a potential wound dressing for treating diabetic wounds, which was further confirmed by both the vitro and vivo studies. In vitro, the MF-gel could promote the migration of healing-related cells from peripheral as well as the angiogenesis and displays the capacity of mediating inflammation response by scavenging the intracellular ROS. In vivo, the MF-gel accelerates wound contraction and healing via inflammatory adjustment, collagen deposition, and angiogenesis. This study provides a facile and effective method for diabetic wound management and emphasizes the direct self-assembly hydrogel from natural herbal small molecule.

Second Metatarsal Length and Transfer Ulcers After First Metatarsal Amputation in Diabetic Foot Infections

BACKGROUND

Plantar transfer ulcers (TUs) underneath the second metatarsal head are frequent after first metatarsal ray amputations due to diabetic foot infections. Whether the second metatarsal length (2ML) is associated with TU occurrence in these patients is unclear. This study evaluated whether 2ML is associated with TU occurrence after first-ray amputations and whether ulcer-free survival is shorter in patients with "excess" 2ML.

METHODS

Forty-two patients with a mean age of 67 (range 33-93) years, diabetes, and first metatarsal ray amputation (first amputation at the affected foot) were included. Two independent readers measured the 2ML using the Coughlin method. A protrusion of more than 4.0 mm of the second metatarsal was defined as "excess" 2ML. The effect of 2ML on ulcer occurrence was analyzed using a multivariate Cox regression model. A Kaplan-Meier curve for TU-free survival was constructed comparing the 2 groups of "normal" (n = 21) and "excess" 2ML (n = 21).

RESULTS

Interrater reliability was excellent. TUs underneath the second metatarsal occurred in 15 (36%) patients. In agreement with our hypothesis, 2ML was nonsignificantly different in patients with TUs, recording a mean of 5.3 (SD 2.5) mm, compared to patients without 4.0 (SD 2.3) mm (hazard ratio [HR] 1.12, 95% CI 0.89-1.41), whereas insulin dependence was associated with ulcer occurrence (HR 0.33, 95% CI 0.11-0.99).

CONCLUSION

In our relatively small study population with a cutoff level of 4 mm for excess 2ML, ulcer-free survival was similar in patients with "normal" and "excess" 2ML.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.