Dystrophic Calcification in Chronic Leg Ulcers—A Clinicopathologic Study

Leg dystrophic calcification as a consequence of chronic diabetic foot infection: a case report

Foot ulceration and infection is associated with a substantial increase in morbidity and mortality in patients with diabetes. We present a clinical case of recurrent diabetic foot infection with an atypical clinical evolution. A 58-year-old male patient with type 1 diabetes and a history of bilateral Charcot foot neuroarthropathy was followed at our Diabetic Foot Clinic for an unhealed plantar foot ulcer for >1.5 years with recurrent episodes of infection. He was admitted to hospital due to foot ulcer reinfection with sepsis and ipsilateral lower limb cellulitis. The foot infection was found to be associated with an underlying abscess in the anterior compartment of the leg, with a cutaneous fistulous course with extensive alterations of an inflammatory nature. Exudate from the lesion was drained and tissue biopsied, revealing Serratia marcescens and Klebsiella oxytoca with dystrophic calcification (DC). Surgical excision of dystrophic tissue with debridement of the fistulous tracts was performed. The excised material corroborated the presence of fibroadipose connective tissue with marked DC, as well as areas of mixed inflammation compatible with a chronic infectious aetiology. Targeted long-term antibiotic therapy was implemented, for a total of six weeks, with a favourable clinical evolution and complete closure of the lesion at the final follow-up. DC results from calcium deposition in degenerated tissues without evidence of systemic mineral imbalance and is a potential cause of non-healing ulcers. Few cases of DC have been reported in diabetic foot patients and its treatment remains challenging and controversial. A longer follow-up period is necessary to verify the effectiveness of our approach.

Systemic Sodium Thiosulfate as an Adjunct Treatment in Calcinosis: A Retrospective Study

(1) Background: Calcinosis of the skin mainly appears in connective tissue disorders (dystrophic subtype). It may cause inflammation, ulceration, pain, and restricted joint mobility. Management is difficult; sodium thiosulfate is one potential therapeutic agent with promising data on intralesional and topical formulation for smaller calcified lesions. There are very limited data on systemic administration. (2) Methods: A retrospective study was conducted at our department to assess the efficacy of oral and intravenous sodium thiosulfate in dystrophic calcinosis between 2003 and 2023. (3) Results: Seven patients were identified, who received systemic sodium thiosulfate (intravenous or oral). The mean duration of calcinosis at the time of administration was 3.8 ± 4 years (range 0-11). Intravenous sodium thiosulfate was administered in doses of 12.5-25 g two or three times during one week of the month for 4.5 ± 3.9 months on average. Orally, 1-8 g was administered daily for 29.1 ± 40.9 months on average. Four of seven patients had a partial response (57.1%). Despite no complete response, pain, ulceration and inflammation frequency decreased, and sodium thiosulfate prevented further progression in responsive patients. (4) Conclusions: Based on our experience and literature data, systemic sodium thiosulfate may be a potential adjunct therapy in calcinosis, especially if inflamed or ulcerating.

Cobalt-Doped Bioactive Glasses for Biomedical Applications: A Review

Improving angiogenesis is the key to the success of most regenerative medicine approaches. However, how and to which extent this may be performed is still a challenge. In this regard, cobalt (Co)-doped bioactive glasses show promise being able to combine the traditional bioactivity of these materials (especially bone-bonding and osteo-stimulatory properties) with the pro-angiogenic effect associated with the release of cobalt. Although the use and local delivery of Co²⁺ ions into the body have raised some concerns about the possible toxic effects on living cells and tissues, important biological improvements have been highlighted both in vitro and in vivo. This review aims at providing a comprehensive overview of Co-releasing glasses, which find biomedical applications as various products, including micro- and nanoparticles, composites in combination with biocompatible polymers, fibers and porous scaffolds. Therapeutic applications in the field of bone repair, wound healing and cancer treatment are discussed in the light of existing experimental evidence along with the open issues ahead.

Ceramic Nanofiber Materials for Wound Healing and Bone Regeneration: A Brief Review

Ceramic nanofibers have been shown to be a new horizon of research in the biomedical area, due to their differentiated morphology, nanoroughness, nanotopography, wettability, bioactivity, and chemical functionalization properties. Therefore, considering the impact caused by the use of these nanofibers, and the fact that there are still limited data available in the literature addressing the ceramic nanofiber application in regenerative medicine, this review article aims to gather the state-of-the-art research concerning these materials, for potential use as a biomaterial for wound healing and bone regeneration, and to analyze their characteristics when considering their application.

Subcutaneous Calcifications in Legs with Chronic Venous Diseases

BACKGROUND

Calcifications in the subcutaneous layer (SCL) have been described by x-rays studies in legs with advanced chronic venous disorders (CVD). However, SCL calcifications are rarely included among the changes CVD-related. The aim of this study was to evaluate the prevalence and morphology of SCL calcifications in legs with CVD of all grades of severity by ultrasonography (US).

MATERIAL AND METHODS

Five hundred legs in 250 patients (148 females and 102 males, mean age 51, range 18-87) referred to the vascular clinic for symptoms and signs of CVD were included. After the Duplex evaluation of deep, superficial, and perforating veins the skin and the SCL were investigated by Duplex sonography. Subjects with other possible cause of SCL calcification were excluded.

RESULTS

According to the CEAP-C classification, 43 legs were classified as C1,189 as C2, 34 as C3, 16 as C4A, 45 as C4B or C, 18 as C5 and finally 16 as C6. Varicose veins were reported in 273 legs, lipodermatosclerosis (LDS) in 79. Subcutaneous calcifications were demonstrated in 35/361 CVD legs in two different locations: in the wall of superficial varicose veins (SVC) or in the subcutaneous tissue unrelated to the path of superficial veins (STC). The SVC were found in 12 out of 273 legs with varicose veins (4.4%). They were found in older patients with severe varicose veins disease (grade 3 of VCSS and disease duration >30 yrs). The STC were found in 24 out of 95 legs in the more advanced CVD stages (C4A-C6 classes). No STC were found in C1, C2, and C3 legs.

DISCUSSION

SVC were found only in legs with severe and long-lasting varicose veins and seem to be related to a chronic severe inflammation of the venous wall. STC are independent from the vein wall and were found only in the damaged areas of legs with severe CVD (C4-C6). They are possibly related to chronic inflammation of the subcutaneous tissue. Their avulsion from the ulcer bed is recommended to facilitate ulcer healing and prevent their recurrence.

Dystrophic calcinosis cutis in chronic venous disease of the lower limbs

Abstract Lower limb ulcers secondary to chronic venous disease (CVD) are a significant public health problem in Brazil and account for about 70% of these ulcers. Despite recent technological advances and the various therapeutic options for treatment of these chronic injuries, several factors may be involved in resistance to treatment. Dystrophic calcinosis cutis (DCC) is a rare and often underdiagnosed condition that, when in conjunction with CVD, may be associated with a refractory healing process. In this article, we report a case of DCC in a patient with CVD and discuss its etiology, pathophysiology and possible treatment options.

Calcinose distrófica cutânea na doença venosa crônica de membros inferiores

Lower limb ulcers secondary to chronic venous disease (CVD) are a significant public health problem in Brazil and account for about 70% of these ulcers. Despite recent technological advances and the various therapeutic options for treatment of these chronic injuries, several factors may be involved in resistance to treatment. Dystrophic calcinosis cutis (DCC) is a rare and often underdiagnosed condition that, when in conjunction with CVD, may be associated with a refractory healing process. In this article, we report a case of DCC in a patient with CVD and discuss its etiology, pathophysiology and possible treatment options.

Calcified leg Ulcers in older patients: clinical description, morphology and chemical characterization

Chronic wounds, including leg ulcers, constitute an important medical problem among older patients. Dystrophic calcifications (DC) are associated with a variety of disorders, including leg ulcers. The aim of this study was to report the clinical and biological characteristics of older patients with DC in leg ulcers and to determine the morphology and chemical composition of these calcifications. We conducted a prospective monocentric study in our Geriatric-Wound and Healing ward, Rothschild Hospital, Paris, from January 2018 to December 2019. Patients with leg ulcers were screened for DC by palpation. Patients' clinical, biological and radiological findings were collected. DC morphology was analyzed using field-emission scanning electron microscopy and chemical composition was analyzed using µFourier transform infra-red spectroscopy and X-ray Fluorescence. Ten (7%) of the 143 patients hospitalized for leg ulcers presented DC. Older patients with DC were more likely to have leg ulcers with venous insufficiency (P=0.015), colonized by Pseudomonas aeruginosa (P=0.026), with a longer healing evolution (P=0.0072) and hypercalcemia (P=0.041). Five DC were extracted from ulcers: two presented 500 nm lacunar spheres and intermingled fibrils of about 10 nm in diameter, consistent with bacterial and biofilm imprints. DC were always composed of Calcium-phosphate apatite and associated to the presence of Zinc. Our analyses were consistent with the involvement of microorganisms and inflammatory process in DC formation. Early management of venous insufficiency, treatment of chronic bacterial colonization and use of calcium-solubilizing drugs seem to be rational strategies for calcified leg ulcer management in older patients.

Bioactive glasses and electrospun composites that release cobalt to stimulate the HIF pathway for wound healing applications

BACKGROUND

Bioactive glasses are traditionally associated with bonding to bone through a hydroxycarbonate apatite (HCA) surface layer but the release of active ions is more important for bone regeneration. They are now being used to deliver ions for soft tissue applications, particularly wound healing. Cobalt is known to simulate hypoxia and provoke angiogenesis. The aim here was to develop new bioactive glass compositions designed to be scaffold materials to locally deliver pro-angiogenic cobalt ions, at a controlled rate, without forming an HCA layer, for wound healing applications.

METHODS

New melt-derived bioactive glass compositions were designed that had the same network connectivity (mean number of bridging covalent bonds between silica tetrahedra), and therefore similar biodegradation rate, as the original 45S5 Bioglass. The amount of magnesium and cobalt in the glass was varied, with the aim of reducing or removing calcium and phosphate from the compositions. Electrospun poly(ε-caprolactone)/bioactive glass composites were also produced. Glasses were tested for ion release in dissolution studies and their influence on Hypoxia-Inducible Factor 1-alpha (HIF-1α) and expression of Vascular Endothelial Growth Factor (VEGF) from fibroblast cells was investigated.

RESULTS

Dissolution tests showed the silica rich layer differed depending on the amount of MgO in the glass, which influenced the delivery of cobalt. The electrospun composites delivered a more sustained ion release relative to glass particles alone. Exposing fibroblasts to conditioned media from these composites did not cause a detrimental effect on metabolic activity but glasses containing cobalt did stabilise HIF-1α and provoked a significantly higher expression of VEGF (not seen in Co-free controls).

CONCLUSIONS

The composite fibres containing new bioactive glass compositions delivered cobalt ions at a sustained rate, which could be mediated by the magnesium content of the glass. The dissolution products stabilised HIF-1α and provoked a significantly higher expression of VEGF, suggesting the composites activated the HIF pathway to stimulate angiogenesis.

The Role of Complex Treatment in Mixed Leg Ulcers - A Case Report of Vascular, Surgical and Physical Therapy

BACKGROUND:

Leg ulcers are a burden to patients, their families and society. The second most common cause of chronic leg ulcers is the mixed arterio-venous type. An 80-year-old female patient presented to our department due to painful enlarging chronic leg ulcer of mixed arteriovenous origin on her left lower leg. She suffered from peripheral arterial occlusive disease stage I and chronic venous insufficiency Widmer grade IIIa, and a number of comorbidities.

AIM:

The aim of our ulcer treatment was a complete and stable wound closure that was hampered by arterial occlusion, exposed tendon, and renal insiffuciency.

CASE REPORT:

To improve the prognosis for ulcer surgery, we performed percutaneous transluminal angioplasty, transcutaneous CO₂ and deep ulcer shaving. The wound was closed by sandwich transplantation using elastin-collagen dermal template and meshed split skin graft. She had a 100% graft take with rapid reduction of severe wound pain.

CONCLUSION:

Complex approaches are necessary, to gain optimum results in leg ulcer therapy in mixed leg ulcers. Therapeutic nihilism should be abandonend.

The role of radical surgery in the management of CEAP C5/6 and lipodermatosclerosis

Aim Analysis of the radical removing of the dermatosclerotic tissues and ulcer(s) with perforator veins dissection as well as local wound and standard compression treatment of CEAP C5/6 stage in a prospective comparative cohort study. Primary endpoint is to compare the results of the one-year follow-up regarding quality of life, vein clinical severity score, and ulcer healing process. Secondary endpoint is the precise presentation of the surgical technique. Tertiary endpoint is to demonstrate the photo-documented results of the postoperative wound treatment protocol. Method Clinical and statistical comparison of radical surgery versus solely wound care and compression in a cohort of 15 patients in each group (Groups 1, 2). In Group 1, radical removing of the dermatosclerotic pannicule and leg ulcer, perforator vein dissection, great saphenous vein, or small saphenous vein was performed. Quality of life , pain intensity, vein clinical severity score and patients' load capacity were compared. The tissue oxygen saturation changes were monitored via near infra-red spectroscopy. Results Both groups were statistically comparable. Wound healing in the operated group was 100% versus 60% in the second one, the difference was significant, p = 0.006. The quality of life: 45.33 versus 36.8, p < 0.001, intensity of leg restless and pain: 2.28 versus 5.3, p < 0.001, changes of vein clinical severity score: 5.27 versus 20.93, p < 0.001, changes of tO_2sat: 19.00 versus 6.07 in the upper third of the leg p < 0.001, proved significantly better in group 1 compared to 2. Load capacity was significantly better in group 1 than 2 at the end of the study. The average wound healing time was 113 days in group 1. Conclusion The radical surgery provides significantly better results, considering quality of life, vein clinical severity score, load capacity than the conservative treatment in this study.

Dystrophic Cutaneous Calcification and Metaplastic Bone Formation due to Long Term Bisphosphonate Use in Breast Cancer

Bisphosphonates are widely used in the treatment of breast cancer with bone metastases. We report a case of a female with breast cancer presented with a rash around a previous mastectomy site and a discharge lesion on her right chest wall in August 2010. Biopsy of the lesion showed dystrophic calcification and metaplastic bone formation. The patient's history revealed a long term use of zoledronic acid for the treatment of breast cancer with bone metastasis. We stopped the treatment since we believed that the cutaneous dystrophic calcification could be associated with her long term bisphosphonate therapy. Adverse cutaneous events with bisphosphonates are very rare, and dystrophic calcification has not been reported previously. The dystrophic calcification and metaplastic bone formation in this patient are thought to be due to long term bisphosphonate usage.