[The frequency of lower limb amputations in Germany]

[Reconstruction of soft tissue defects of the lower extremities]

A reliable reconstruction of soft tissue defects of the lower extremities especially in the distal third of the leg is still a special challenge for reconstructive surgeons. The possibility of salvaging the leg has to be evaluated in the setting of an interdisciplinary team and the timing of the operation(s) with respect to the safety of the patient and a systematic approach with the selection of a suitable flap have to be defined. Traditionally local muscle flaps or free flaps have been established for coverage of defects of the lower extremities. Recently perforator-based flaps have gained popularity for reconstruction of lower extremity defects. Furthermore, new surgical techniques and developments in association with the demographic change have led to a paradigm shift.

Preulcerous Risk Situation in Diabetic Foot Syndrome: Proposal for a Simple Ulcer Prevention Score

BACKGROUND

Preulcerous risk situations in patients with diabetes are often undiagnosed and care administered too late. Even with regular medical check-ups and status documentation, foot examinations have not been given enough attention. Diagnosing an individual patients' risk of developing diabetic foot ulcers may increase vigilance for diabetic foot syndrome (DFS), and the appropriate prevention measures matching the risk involved may prevent the emergence of diabetic ulcers. The classical DFS risk factors are well established and have been extensively covered in the literature; however, there is a lack of efficient screening tools that could be used for a rapid assessment of diabetic foot ulcer risk.

METHODS

A methodical literature search was conducted to assess relevant publications for the preparation of a simple risk score for amputation related to diabetic foot ulcer. We then analyzed the risk factors for predictive value as odds ratios in foot ulcers and/or amputation. We used the available data to deduce a mean value to reflect the authors' consensus.

RESULTS

In view of the current literature on the matter, we have developed a semi-quantitative scoring system using just a few items to allow rapid and visual risk assessment for diabetic foot ulcers alongside recommendations for prevention and a sensible follow-up strategy to match the risk.

CONCLUSION

This relatively simple score enables rapid risk classification for patients that can ease the way for both physicians and patients in gaining an insight into individual risk situations. The score provides more effective preventative measures for high-risk patients against future complications.

The prevalence of osteoarthritis: Higher risk after transfemoral amputation?-A database analysis with 1,569 amputees and matched controls

Background

Several studies have shown that patients with a unilateral amputation have an increased risk of developing osteoarthritis (OA) in the knee of their sound leg. OBJECTIVE: The first objective was to investigate whether amputees are more frequently affected by gon-, cox- or polyarthritis as well as back pain or spinal disorders. We hypothesized that mobile and active transfemoral amputees more often experience OA and spinal disorders than non-amputees. The second objective was to compare the mean age of the patients with OA.

Patients

Patients with a unilateral transfemoral amputation (n = 1,569) and five abled-body control groups (each n = 1,569) matched in terms of age and gender resulting in total of 9,414 participants.

Methods

Groups were analyzed regarding the prevalence of six selected diagnoses regarding musculoskeletal disorders.

Results

A significantly decreased prevalence of OA and specific disorders of the spine in transfemoral amputees compared to a control group was found. The amputees with OA are significantly younger than patients with OA in the control group.

Conclusion

The results from the presented study contradict previously published literature. Apparently circumstances of life play an important role, like physical work and strenuous activities which are likely to be underrepresented in the amputee group. The results of the study need to be used cautiously due to the major limitation of the study which is the lack of detail in individual patients caused by the methodology.

[Operative treatment of diabetics with vascular complications : Secondary data analysis of diagnosis-related groups statistics from 2005 to 2014 in Germany]

BACKGROUND

In Germany approximately 40,000 amputations per year are performed on patients with diabetes mellitus, often with accompanying vascular complications.

OBJECTIVE

The aim of this study was to present the various degrees of severity of the vascular complications and the temporal changes of the treatment options in diabetics with vascular complications in Germany.

MATERIAL AND METHODS

The microdata of the diagnosis-related groups (DRG) statistics of the Federal Statistical Office were analyzed over the period from 2005 to 2014. All cases were included in which the main or secondary diagnosis of diabetes mellitus with concurrent vascular complications (diabetic angiopathy and peripheral arterial disease) was encrypted.

RESULTS

The median age of the 1,811,422 cases was 73 years and 62% were male. While the total number of amputations remained stable over time, there was a 41% reduction in knee-preserving and a 31% reduction in non-knee preserving major amputations with an 18% increase in minor amputations. Revascularization increased by 33% from 36 procedures in 2005 to 48 procedures per 100,000 inhabitants. The increase in revascularization was evident in the area of endovascular therapy alone where there was an increase of 78%.

CONCLUSION

Due to the significant increase in endovascular revascularization measures, there was a significant increase in the proportion of diabetes patients with vascular pathologies in whom revascularization was carried out. As a result, improved limb preservation was achieved despite equally high amputation rates due to increasing minor amputation rates.

Decrease in (Major) Amputations in Diabetics: A Secondary Data Analysis by AOK Rheinland/Hamburg

AIM

In two German regions with 11.1 million inhabitants, 6 networks for specialized treatment of DFS were implemented until 2008. Data provided for accounting purposes was analysed in order to determine changes in the rate of diabetics requiring amputations in the years before and after the implementation.

METHOD

Data covering 2.9 million people insured by the largest insurance company between 2007 and 2013 was analysed by the use of log-linear Poisson regression adjusted for age, gender and region.

RESULTS

The rate of diabetics needing major amputations fell significantly by 9.5% per year (p < 0.0001) from 217 to 126 of 100,000 patients per year. The rate of diabetics needing amputations of any kind fell from 504 to 419 of 100,000 patients per year (p = 0.0038).

DISCUSSION

The networks integrate health care providers in an organised system of shared care. They educate members of the medical community and the general public. At the same time, a more general disease management program for people with diabetes was implemented, which may also have contributed to this decrease. At the end of the observation period, the rate of diabetics requiring amputations was still high. For this reason, further expansion of organised specialized care is urgently needed.

[Minor amputations: a maxi task : Part 2: From transmetatarsal amputation to hindfoot amputation]

The definitive aim of a minor amputation is limited resection with retention of feet and legs resulting in a completely loadable extremity, in contrast to the lower leg stump. A shift in the amputation level in the sense of a shortening is inevitably accompanied by a reduction in the stand area, an increase in axial pressure and a disruption of muscle equilibrium in the extent of movement of the rest of the foot. This knowledge forms the central issue for further treatment of minor amputations in addition to the subtle treatment of the skin of the sole for coverage of a tension-free tip of the stump. Advantageous are longitudinal partial amputations of the forefoot and midfoot.

Structured health care for subjects with diabetic foot ulcers results in a reduction of major amputation rates

Objective

We tested the effects of structured health care for the diabetic foot in one region in Germany aiming to reduce the number of major amputations.

Research design and methods

In a prospective study we investigated patients with diabetic foot in a structured system of outpatient, in-patient and rehabilitative treatment. Subjects were recruited between January 1^st, 2000 and December 31, 2007. All participants underwent a two-year follow-up. The modified University of Texas Wound Classification System (UT) was the basis for documentation and data analysis. We evaluated numbers of major amputations, rates of ulcer healing and mortality. In order to compare the effect of the structured health care program with usual care in patients with diabetic foot we evaluated the same parameters at another regional hospital without interdisciplinary care of diabetic foot (controls).

Results

684 patients with diabetic foot and 508 controls were investigated. At discharge from hospital 28.3% (structured health care program, SHC) vs. 23.0% (controls) of all ulcers had healed completely. 51.5% (SHC) vs. 49.8% (controls) were in UT grade 1.

Major amputations were performed in 32 subjects of the structured health care program group (4.7%) vs. 110 (21.7%) in controls (p<0.0001). Mortality during hospitalization was 2.5% (SHC) vs. 9.4% in controls (p<0.001).

Conclusions

With the structured health care program we achieved a significant reduction of major amputation rates by more than 75% as compared to standard care.

Amputation rate and risk factors in type 2 patients with diabetic foot syndrome under real-life conditions in Germany

AIMS

To determine the risk of amputation and the influencing factors for amputation for patients with type 2 diabetes with diabetic foot syndrome.

METHODS

Longitudinal data from general practices in Germany (Disease Analyzer database, IMS Health) were analyzed. 3892 type 2 diabetes patients (mean age: 66.0 (SD: 10.9 years), 39.1% female) with a first-time diagnosis of diabetic foot syndrome between 01/200 and 12/2004 and at least 5 year follow-up documentation in the practices were included. The analyses of amputation-free survival were carried out using Kaplan-Meier curves and log-rank tests. A multivariate Cox regression model was fitted with the incident of diabetes-associated amputations as the dependent variable and adjusted for clinical and demographic characteristics.

RESULT

The cumulative incidence of diabetes-associated lower limb amputations was 18.2%. Amputations are independently associated with higher age, male gender, higher HbA1c value and longer diabetes duration but also some other diabetes complications.

DISCUSSION

The diabetic foot syndrome can but must not lead to a lower limb amputation. Due to the great medical and economic burden on the health system caused by diabetic complications, early therapeutic intervention is essential for patients with diabetic foot syndrome.

[Minor amputations - a maxi task. Part 1: From the principles to transmetatarsal amputation]

A threatening major amputation represents a fateful turning point for diabetics. This occurs in 50% of cases of amputations in diabetics. This increases the demand for another therapeutic route not only because of the limitations in quality of life but also due to substantially higher mortality. Even if an osteomyelitic ischemic situation is often present specialized centers have succeeded in substantially reducing the rate of major amputations in such patients. The term "minor amputation" commonly used in vascular surgery is not uniformly understood. Following the "vascular surgery working model" developed by Rümenapf, the significance of "minor amputations" for retention of extremities and the associated controversies have been shown. "Minor amputations" therefore represent a maxi-task if patients undergoing such a procedure are to be timely and competently treated. The necessary interdisciplinary cooperation with other specialists should in the future also include orthopedic surgeons.

Autologous stem cell therapy in the treatment of limb ischaemia induced chronic tissue ulcers of diabetic foot patients

BACKGROUND AND AIM

Despite improvements in surgical revascularisation, limitations like anatomical factors or atherosclerosis limit the success of revascularisation in diabetic patients with critical limb ischaemia. Stem cells were shown to improve microcirculation in published studies. The aim of this study was to evaluate safety, feasibility and efficacy of transplantation of bone marrow derived cellular products regarding improvement in microcirculation and lowering of amputation rate.

METHODS

Bone marrow mononuclear cells (BMCs) in comparison with expanded bone marrow cells enriched in CD90+ cells ('tissue repair cells', TRCs) were used in the treatment of diabetic ulcers to induce revascularisation. Diabetic foot patients with critical limb ischaemia without option for surgical or interventional revascularisation were eligible. Parameters examined were ABI, TcPO(2) , reactive hyperaemia and angiographic imaging before and after therapy.

RESULTS

Of 30 patients included in this trial, 24 were randomised to receive either BMCs or TRCs. The high number of drop-outs in the control group (4 of 6) led to exclusion from evaluation. A total of 22 patients entered treatment; one patient in the TRC group and two in the BMC group did not show wound healing during follow up, one patient in each treatment group died before reaching the end of the study; one after having achieved wound healing (BMC group), the other one without having achieved wound healing (TRC group). Thus, 18 patients showed wound healing after 45 weeks. The total number of applicated cells was 3.8 times lower in the TRC group, but TRC patients received significantly higher amounts of CD90+ cells. Improvement in microvascularisation was detected in some, but not all patients by angiography, TcPO(2) improved significantly compared with baseline in both therapy groups.

CONCLUSION

The transplantation of BMCs as well as TRCs proved to be safe and feasible. Improvements of microcirculation and complete wound healing were observed in the transplant groups.

[Diagnostics and therapy of the diabetic foot syndrome from a vascular surgery perspective]

There are more than 6 million diabetic patients in Germany. Due to neuropathic and angiopathic long term damage the number of patients with diabetic foot syndrome has been increasing dramatically over the past years. Despite all efforts for prevention, early diagnosis and adequate therapy, more than 20,000 diabetics undergo major limb amputation in Germany every year. A major portion of these amputations could be avoided if an improvement of the arterial perfusion would be timely considered. By consequent therapy in interdisciplinary centres, and by applying all methods of arterial revascularization, the amputation rate in patients with diabetic foot problems could be reduced by 80%. This article describes the diagnostics and therapy of the diabetic foot syndrome from a vascular surgical point of view. The importance of endovascular, vascular surgical as well as combined (hybrid) procedures of revascularization is emphasized.

[Epidemiology and classification of diabetic foot syndrome]

The diabetic foot syndrome (DFS) is an important complication of diabetes mellitus resulting in severe undesired consequences, such as amputation, disability and reduced quality of life. In Germany there are approximately 300,000 patients with lesions of the foot caused by diabetes of which approximately 50% have to be amputated within 4 years of diagnosis. To achieve a reduction of the amputation rate it is necessary to identify the main causes. The use of the Wagner-Armstrong wound classification is well accepted in Germany. Therapy and diagnosis of the diabetic foot syndrome are almost standardized and all procedures are well established. In addition a professional stage-adjusted wound therapy has to take place in an interdisciplinary collaboration at a centre for wound care.

[Diabetic foot syndrome from the perspective of angiology and diabetology]

The diabetic foot syndrome (DFS) is one of the most significant complications of diabetes mellitus and frequently leads to amputation of the affected extremity. Cardiovascular mortality and morbidity of affected patients are still high and healed ulcers often recur. The pathogenesis of DFS is complex, clinical presentation is variable and management requires early expert assessment. Interventions should be directed towards infection, peripheral ischemia and pressure relief caused by peripheral neuropathy and limited joint mobility. Treatment includes wound clean-up, stage-oriented local wound management and the appropriate treatment of bacterial infection. Useful preventive measures are blood glucose control training of diabetics, regular foot care and the provision of appropriate footwear.

[Minor amputations for diabetic foot syndrome]

Minor amputations are frequently performed for neuroischemic or neuropathic lesions of the diabetic foot. Depending on the definition used, minor amputations can range from toe to Syme amputations. Minor amputations are often combined with necrosectomy and débridement. For early and optimal rehabilitation, as much vital tissue as possible should be conserved, especially considering the skeletal structures of the foot (borderline amputation). Minor amputations are of utmost importance for the prevention of ascending infections and reduce the duration of clinical and outpatient treatment. Minor amputations should be performed only by experienced surgeons and only if arterial perfusion is sufficient. They should be as tissue-conserving as possible and structured interdisciplinary postoperative care is mandatory. Metabolic control should be optimized. Controversial opinions exist with respect to the use of tourniquets, conservation or resection of cartilage and sesamoid bones, open amputation or primary closure of the wound, interdigital spacer function of toes, aseptic proximal transection of tendons, postoperative wound care, negative-pressure wound treatment and antibiotic therapy. In view of these controversies the most important minor amputation techniques are described and discussed.

[Diabetic foot syndrome]

Ulceration of the foot in diabetes is common and disabling and frequently leads to lower extremity amputation. Mortality and morbidity is still high and healed ulcers often recur. The pathogenesis of diabetic foot syndrome is complex, clinical presentation variable and management requires early expert assessment. Interventions should be directed at infection, peripheral ischemia and pressure relief caused by peripheral neuropathy and limited joint mobility. Treatment includes wound clean-up, stage-oriented local wound management, and the appropriate treatment of bacterial infection. Useful preventive measures are training of diabetics, regular foot care and the provision of appropriate footwear.

[The diabetic foot]

In the last 20 years the prevalence of diabetes in Germany has increased by approximately 50%. Associated with this is a distinct rise of diabetes-induced comorbidities and long-term consequences. One of the most frequent consequences is the diabetic foot or the diabetic foot syndrome. This is an ulceration of neuropathic and angiopathic origin, which often reaches a chronic stadium due to a poor healing tendency. Despite the disease management program for diabetes in Germany which mainly concentrates on the prophylaxis and multidisciplinary treatment of chronic diseases, there are approximately 250,000 patients with lesions of the foot caused by diabetes of which approximately 50% have to be amputated within 4 years. To achieve a reduction of the amputation rate identification of the main reasons is necessary. In addition a professional therapy of the vascular disorders and a stage-adjusted wound therapy have to take place in an interdisciplinary collaboration in a centre for wound care. Last but not least this aim can only be achieved by a preventive education of diabetics.

[The vascular surgeon's role in interdisciplinary treatment of diabetic foot syndrome]

There are more than 6 million diabetes patients in Germany. Due to long-term neuropathic and angiopathic sequelae, the number of patients with "diabetic foot syndrome" has increased dramatically in recent years. Diabetic foot ulcers have become one of the most common pathologies in interdisciplinary wound care centers. Because of its complex pathogenesis, diabetic foot syndrome needs a multidisciplinary therapeutic approach. More than 150,000 diabetics per year develop foot ulcers that often heal slowly and progress into chronic wounds. Despite all efforts at prevention, early diagnosis, and adequate therapy, more than 20,000 diabetics suffer major limb amputation in Germany every year. Applying stringent standards of care in interdisciplinary wound care centers, the amputation rate in patients with diabetic foot syndrome can be reduced to less than 50%. This article describes the complexity of diabetic foot syndrome with respect to pathogenesis, diagnostics, and therapy from a vascular surgeon's point of view. The importance of an interdisciplinary approach is emphasized.

[Current status of vascular surgery : in vascular medicine and general surgery]

BACKGROUND

The proportion of arterial and venous diseases is increasing due to shifts in population. Therapy is based on conventional vascular surgery and conservative endovascular methods.

MATERIAL AND METHODS

Based on data from the Federal German Statistics Office and the Federal Chamber of Physicians, information was gathered on primary vascular diseases, active special vascular groups, surgical qualifications, and surgical clinics. Additionally, the status of vascular surgery at university clinics and non-university clinics with more than 900 beds was assessed.

RESULTS

In 2004, 413,763 patients with primary vascular disease were treated in 1,846 German general hospitals. More than 70% of these patients were handled in vascular surgical or general surgical clinics, and operations were performed in 50% of cases. There exist independent vascular surgical departments in 213 hospitals. Thirty-three university clinics at 38 locations showed a total of six independent vascular surgery clinics (16%) and seven partially independent sections (18%). Vascular surgery is done within cardiac surgical departments in ten clinics and in general surgery department in 15 clinics. In contrast, there are independent vascular surgical departments in 39% and 53% of non-university clinics with more than 900 and 600-899 beds respectively.

CONCLUSIONS

Vascular surgery has been established in hospitals as an independent speciality. This development must continue in general surgical and university clinics.

Wound therapy with autologous bone marrow stem cells in diabetic patients with ischaemia-induced tissue ulcers affecting the lower limbs

Previous studies suggest that autologous transplantation of bone marrow mononuclear cells is safe and effective in inducing therapeutic angiogenesis in patients with peripheral arterial occlusive disease (PAOD). Here we discuss a multidisciplinary approach to treating PAOD with a focus on the use of angiological diagnostic tools. We conclude that our autologous stem cell therapy is working in this patient and it is a potential new therapeutic option for diabetic patients with chronic foot ulcers induced by critical limb ischaemia.