Medium-term outcomes of multi-disciplinary surgical management of non-ischemic diabetic heel ulcers

Clinical Effects of Thread-Dragging Therapy on Gangrene of Non-ischemic Diabetic Foot Ulcers

OBJECTIVE

To investigate the clinical effects of thread-dragging therapy on gangrene of non-ischemic diabetic foot ulcers (NIDFU).

METHODS

A total of 136 patients with NIDFU were recruited from the Department of Peripheral Vascular Surgery, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine between June 21, 2021 and February 1, 2023, and randomized into an intervention group and a control group, with 68 cases in each group. Both groups received basic treatment. The intervention group was treated with thread-dragging therapy, while the control group was treated with debridement combined with routine dressing changes after surgery. Both groups were treated continuously for 2 months. The amputation rates and changes in the ulcer area were compared between the groups. The inflammatory response index including peripheral white blood cells (WBCs), neutrophil percentage (NEUT%), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT), and interleukin 6 (IL-6) were compared between the two groups.

RESULTS

After treatment, the ulcer areas in the intervention group were significantly smaller than that of the control group (8.50±3.88 cm2 vs. 10.11±4.61 cm2, P<0.05). The amputation rates of the two groups were not statistically significant (4.4% vs. 5.9%, P>0.05). Differences of WBCs count, CRP, and ESR before and after therapy in the intervention group were better than the control group (P<0.05). However, there were no significant differences in changes of NEUT%, PCT, and IL-6 between the two groups (P>0.05).

CONCLUSION

Thread-dragging therapy may be effective in the treatment of NIDFU, with the additional advantages of less tissue damage after healing. (Registration No. ChiCTR2100047496).

Descriptive Analysis of Anatomical Location and Metabolic and Microbiological Factors in Diabetic Foot (DF) Treated at a DF Specialty Tertiary Care Hospital With a Multidisciplinary Approach

Background and aims The outcome of a diabetic foot ulcer (DFU) may be affected by many factors, including the clinical anatomy of the ulcer, metabolic control, the presence of complications, and infections. This study evaluates the effect of metabolic factors, the clinical anatomy of the ulcer at presentation, and antibiotic appropriateness on treatment outcomes in terms of amputation in patients with diabetic foot (DF). Materials and methods This is a cross-sectional observational study involving data collected from patients with IPD diagnosed with type 2 diabetes mellitus and DFU at a tertiary care DF specialty hospital in Maharashtra, India. Results Data from a total of 106 patients were included for analysis. Fifty-two patients healed without amputation while 54 underwent either minor or major amputation. Patients who did not require amputation had a statistically significant higher incidence of cellulitis, ulcers at the heel and lateral malleolus, and ulcers classified as Wagner grade 1 or 2. In contrast, factors significantly associated with amputation included lower weight and BMI, multiple ulcers at presentation, ulcers involving the second, third, fourth, or fifth toe, midfoot, or medial malleolus, ulcers graded 3, 4, or 5, and additional surgery performed during the same hospital admission. The most commonly collected specimen was pus, followed by tissue and bone. The most frequently isolated microorganisms were Escherichia (E.) coli and Klebsiella. All microorganisms were sensitive to Piperacillin-Tazobactam and matched the initially prescribed antibiotic, which was chosen as per the hospital antibiogram. Angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blockers (ARBs) were prescribed more frequently in the non-amputation group while insulin use was higher in the amputation group, although there was no significant difference in the use of metabolic drugs between the two groups. Conclusion The anatomical location of the wound, advanced grade, number of ulcers, additional procedures, nutritional status, and the presence of Coagulase-negative Staphylococcus aureus in tissue are significant predictors of amputation.

Clinical characteristics, treatment and efficacy of calcaneal osteomyelitis: a systematic review with synthesis analysis of 1118 reported cases

BACKGROUND

Calcaneal osteomyelitis (CO) still poses great challenges to orthopedic surgeons due to the unique anatomic and functional features of the calcaneus. This study summarized the current data regarding clinical characteristics, treatment and efficacy of CO, based on an analysis of literature-reported cases.

MATERIALS AND METHODS

The authors searched the PubMed, Embase, and Cochrane Library databases to find English and Chinese studies reporting on CO patients published between 2000 and 2021, with available data for synthesis analysis. The quality of the included studies was evaluated by the National Institutes of Health (NIH) assessment scale. Effective data were extracted and pooled for analysis.

RESULTS

Altogether 198 studies involving 1118 patients were included, with a male-to-female ratio of 2.3 (724 males and 310 females). The median age at CO diagnosis was 46 years, with a median symptom duration of 3 months. Injury-related infections (524 cases) and diabetic foot infections (336 cases) were the two most common causes, with ulcers (468 cases) and wound sinus or exudation (209 cases) being the predominant symptoms. The overall positive culture rate was 80.2%, with polymicrobial infections accounting for 18.1%. Staphylococcus aureus was the most frequently detected pathogen (42.7%), with fungal-related infections isolated in 17 cases. Although most patients received surgical interventions (96.9%), the recurrence rate was 20.1%. The incidence of infection relapse following partial calcanectomy, total calcanectomy, debridement with implantation of local antibiotics, and debridement with or without flap or skin coverage were 31.7%, 45.0%, 16.8%, and 15.1%, respectively. The overall incidence of limb amputation was 12.4%, with all-cause and CO-related mortalities of 2.8% and 0.2%, separately.

CONCLUSIONS

CO shared similar characteristics with extremity chronic osteomyelitis, primarily affecting young males, with trauma and diabetic foot as the leading causes and Staphylococcus aureus as the most frequently detected pathogen. Despite surgery being the primary treatment modality, clinical outcomes remained unsatisfactory, marked by high rates of infection recurrence and limb amputation.

Impact of multidisciplinary management via special clinic for the outcome of diabetic foot disease: A prospective observational study

Introduction

Diabetic foot is a common complication of diabetes mellitus, affecting approximately 15-20% of individuals with diabetes. It is a comorbid condition that significantly impacts the routine life of patients. This study aimed to assess multidisciplinary management strategies and their impact on the outcomes of patients with diabetic foot.

Methods

A prospective observational study was conducted on 56 patients with diabetic foot. Outcome measures included the type of surgery, frequency of surgery, morbidity, mortality, patient satisfaction, return to work, and the number of patients using prostheses.

Results

The majority of the patients (87%) received surgical treatment. The most common type of surgery performed was debridement (55%), followed by minor amputations (toes amputation/forefoot amputation) (28%) and major amputations (below-knee (B/K) or above-knee (A/K)) (15%). More than 70% of patients had multiple surgeries. The mortality rate was low (7%), and 71% of surviving patients were satisfied with their treatment. Sixty-seven percent of patients had an early return to work. The number of patients using prostheses was also high (73% of major amputation cases).

Conclusion

Multidisciplinary management is the most effective approach for diabetic foot patients. These patients may experience less morbidity and an early return to work. A specialized care clinic for diabetic foot patients is essential to prevent treatment failure, loss of follow-up records, permanent limb loss, and economic burdens on society.

Implementation and Outcomes of Multidisciplinary Diabetes Management Program Among Type 2 Diabetic Patients: A Comparative Study

BACKGROUND

Current guidelines recommend shifting physician-led care (PLC) for type 2 diabetes mellitus (T2DM) to more effective multidisciplinary health care (MHC). However, few researchers have studied its real-life implementation in Saudi Arabia. Therefore, we aimed to assess the implementation and compare the outcomes of an MDC diabetes management program (DMP) among T2DM patients to a PLC at a general hospital after one year of follow-up in a real-world practice setting.

METHODS

We conducted this comparative patient files review study by analyzing medical records of all T2DM patients at two private care centers. Both were compared for their effectiveness in achieving two outcomes: the glycated hemoglobin (HbA1c) <7% and low-density lipoprotein-cholesterol (LDL-c) <70 mg/dl at the end of the first year. Additionally, we assessed the implementation of the DMP.

RESULTS

Eight hundred thirty-four medical records were reviewed, 537 from DMP, and 279 from the PLC center. The personal health coordination was almost complete (97.8%) in the DMP, but the implementation was incomplete regarding nutrition (65.7%), dental exam (64.8%), and foot care (58.3%). Both care groups were matched for age (p = 0.056), gender (p = 0.085), duration of diabetes (p = 0.217), and basal glycemic control (p = 0.171). The DMP showed a significant net decrease in HbA1c (-0.5 [IQR 1.47%] vs -0.2 [IQR 3.05%], p = 0.0001) and LDL-c (-10 [IQR 50] vs -5 [IQR 60.5] mg/dl, p = 0.004) compared to PLC. A higher percentage of patients achieved glycemic control in the DMP than in the PLC (49.4% vs 38.7%, p = 0.038). However, both programs demonstrated similar outcomes in lipid control (28.7% vs. 30%, p = 0.695).

CONCLUSION

Despite some gaps in implementation, one year of DMP showed better glycemic control among T2DM patients compared to PLC. Both programs were comparable in terms of lipid control. Further studies identifying the gaps in care implementation could improve sustainability, future replication, and generalizability of similar programs to other healthcare systems in Saudi Arabia.

Investigation and management of diabetic foot osteomyelitis: An update for the foot and ankle orthopaedic surgeon

Diabetic foot osteomyelitis (DFO) poses a significant challenge in the management of diabetic patients, often leading to severe complications and increased morbidity. Effective management of DFO requires a multidisciplinary approach, involving endocrinologists, infectious disease specialists, vascular surgeons, orthopaedic surgeons, and wound care experts. Early diagnosis is paramount, facilitated by advanced imaging techniques such as magnetic resonance imaging (MRI) and bone scintigraphy. Once diagnosed, the treatment strategy hinges on a combination of medical and surgical interventions. Antibiotic therapy, guided by culture results, plays a central role in managing DFO. Tailored regimens targeting the specific pathogens involved are administered, often for prolonged durations. Surgical intervention becomes necessary when conservative measures fall short. Surgical approaches range from minimally invasive procedures, like percutaneous drainage, to more extensive interventions like debridement and bone resection. Prevention of DFO recurrence is equally vital, emphasising glycemic control, meticulous foot care, patient education, monitoring of at-risk signs, revascularization and early intervention when indicated. The management of diabetic foot osteomyelitis mandates a comprehensive strategy that addresses both the infectious and surgical aspects of the condition. A collaborative, interdisciplinary approach ensures timely diagnosis, tailored treatment, and holistic care. Further research into novel therapeutic modalities and long-term outcomes remains essential in refining the management of this complex and debilitating complication of diabetes.

Tangshen Decoction Enhances Podocytes Autophagy to Relieve Diabetic Nephropathy through Modulation of p-AMPK/p-ULK1 Signaling

Traditional Chinese medicine has certain advantages in the prevention and treatment of diabetic nephropathy (DN); thus, Chinese medicine therapy is considered as a promising strategy for treating DN. Here, the diabetic nephropathy model was established and intervened with Tangshen Decoction to explore its repair effect on diabetic kidney injury and the mechanism of autophagy. Different doses (10, 20 g·kg⁻¹) of Tangshen Decoction (so-called Tangshen Jian, TSJ) or metformin were used to intervene for 16 weeks. The body weight (BW) and fasting blood glucose (FBG) of rats in each group were regularly monitored; a urine protein test kit (CBB method) was used to detect changes in urine protein (UP) content. The serum biochemical indicators, including Cr (creatinine), BUN (blood urea nitrogen), TC (total cholesterol), and TG (triglyceride), were detected by an automatic biochemical analyzer. HE (hematoxylin-eosin) staining, PAS, and electron microscopy were used to observe the podocyte damage. We showed that administration of TSJ or metformin prevented the increases in FBG level, serum Cr, BUN, TC, and TG level, and urine protein excretion in diabetic nephropathy. Simultaneously, the foot process fusion and fall-off were partially reversed after TSJ treatment. TSJ or metformin markedly upregulated the level of nephrin and podocin, accompanied by evident enhancement of podocyte autophagy and activation of p-AMPK/p-ULK1 signaling in the diabetic nephropathy. Therefore, TSJ may enhance podocyte autophagy to relieve diabetic nephropathy through modulation of p-AMPK/p-ULK1 signaling, which has important application prospects in the clinical treatment of diabetic kidney damage in the future.

Complex Foot Infection Treated With Surgical Debridement and Antibiotic Loaded Calcium Sulfate-A Retrospective Cohort Study of 137 Cases

Complex foot infections involving bone and soft tissue in patients with co-morbidities such as diabetes and peripheral arterial disease (PAD) are a cause of significant hospital admission. They are associated with substantial economic costs to health services worldwide. Historically, severe foot infection has been treated with surgical debridement and prolonged courses of systemic antibiotics. Prolonged systemic antibiotic use increases the risk of drug side effects, antimicrobial resistance and Clostridium difficile infection. The purpose of this study was to investigate whether surgical debridement and implantation of antibiotic loaded calcium sulfate is effective in the resolution of foot infection and wound healing. A retrospective cohort study of 137 consecutive cases of osteomyelitis (127) or significant soft tissue infection (10) over 62 months from 02/2013 to 04/2018 was conducted following local ethical approval. All cases of infection were treated with surgical debridement and local antibiotic-loaded calcium sulfate. The primary outcomes of infection resolution, time to healing and duration of postoperative antibiotics were measured. In 137 cases, 88.3% of infections resolved. Infection was eradicated in 22 patients without postoperative systemic antibiotics. About 82.5% of wounds healed, with an average healing time of 11.3 weeks. Healing time was significantly increased for the co-morbidities of diabetes and PAD (p =< .05) and for those requiring prolonged systemic postoperative antibiotics. Conservative surgical debridement and implantation of local antibiotic impregnated calcium sulfate is safe and effective in managing complex foot infections. We advocate early surgical intervention before deeper tissue involvement to help preserve lower limb structure and function.

Fluid management and strength postsimulated use of primary and secondary dressings for treating diabetic foot ulcers: Robotic phantom studies

Non-offloaded diabetic heel ulcers and the wound dressings used to treat them may be subjected to considerable bodyweight forces. A novel robotic foot phantom with a diabetic heel ulcer was designed and constructed to test the combined performances of applied primary and secondary dressings, in simulated non-offloaded (standing) and offloaded (supine) postures. We specifically compared the performances of the primary Exufiber dressing (Mölnlycke Health Care) combined with the secondary Mepilex Border Flex dressing (Mölnlycke) against a corresponding pair from an alternative manufacturer. Fluid retention and distribution between the primary and secondary dressings of each pair were determined using weight tests, and mechanical strength of the primary dressings was further measured postsimulated use through tensile testing. The Exufiber and Mepilex Border Flex pair performed similarly in the two simulated postures (retention = ~97%), whereas the comparator pair exhibited a 13%-decrease in retention for a supine to standing transition. Furthermore, the Exufiber dressing delivered up to 2-times more fluid to its paired secondary dressing and endured 1.7-times greater strain energy than the corresponding primary dressing before failure occurred. The present robotic foot phantom and associated methods are versatile and suitable for testing any dressing, in consideration of the relevant clinical factors and practice.