Comparison of WIFi, University of Texas and Wagner Classification Systems as Major Amputation Predictors for Admitted Diabetic Foot Patients: A Prospective Cohort Study

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.

Prediction models for amputation after diabetic foot: systematic review and critical appraisal

BACKGROUND

Numerous studies have developed or validated prediction models aimed at estimating the likelihood of amputation in diabetic foot (DF) patients. However, the quality and applicability of these models in clinical practice and future research remain uncertain. This study conducts a systematic review and assessment of the risk of bias and applicability of amputation prediction models among individuals with DF.

METHODS

A comprehensive search was conducted across multiple databases, including PubMed, Web of Science, EBSCO CINAHL Plus, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, Chinese Biomedical Literature Database (CBM), and Weipu (VIP) from their inception to December 24, 2023. Two investigators independently screened the literature and extracted data using the checklist for critical appraisal and data extraction for systematic reviews of prediction modeling studies. The Prediction Model Risk of Bias Assessment Tool (PROBAST) checklist was employed to evaluate both the risk of bias and applicability.

RESULTS

A total of 20 studies were included in this analysis, comprising 17 development studies and three validation studies, encompassing 20 prediction models and 11 classification systems. The incidence of amputation in patients with DF ranged from 5.9 to 58.5%. Machine learning-based methods were employed in more than half of the studies. The reported area under the curve (AUC) varied from 0.560 to 0.939. Independent predictors consistently identified by multivariate models included age, gender, HbA1c, hemoglobin, white blood cell count, low-density lipoprotein cholesterol, diabetes duration, and Wagner's Classification. All studies were found to exhibit a high risk of bias, primarily attributed to inadequate handling of outcome events and missing data, lack of model performance assessment, and overfitting.

CONCLUSIONS

The assessment using PROBAST revealed a notable risk of bias in the existing prediction models for amputation in patients with DF. It is imperative for future studies to concentrate on enhancing the robustness of current prediction models or constructing new models with stringent methodologies.

Potassium permanganate in treatment of diabetic foot ulcer: A randomized clinical trial

Background and Aims

Diabetic foot ulcers (DFU) are a severe complication in diabetes patients, often resulting in significant morbidity and mortality due to non-healing. This study investigated the effectiveness of 5% topical potassium permanganate on these ulcers.

Methods

A clinical trial was conducted on 23 patients with Wagner grade I and II DFU. Patients in the control group received standard treatment, while those in the intervention group also received 5% potassium permanganate topically. Data were recorded at 0, 7, 14, and 21 days for analysis.

Results

Among 23 patients studied, 7 (30.4%) were male and 16 (43.7%) female, with an average age of 59 ± 4 years. Both groups showed a statistically significant decrease in wound size and infection over time (p < 0.001). The intervention group, however, had a more substantial reduction in wound size and infection rate (p < 0.05).

Conclusion

Potassium permanganate, when applied topically, is both well-tolerated and effective in enhancing wound healing and reducing infection in DFU, suggesting its potential as a complementary treatment.

SVS WIfI score as a predictor of amputation after onset of CLI: Validation in an Irish tertiary vascular unit

INTRODUCTION

Critical limb ischemia (CLI) in diabetic patients is defined by non-healing foot ulcer or rest pain for more than 2 weeks with ankle pressure of less than 40 mmHg. The SVS WIfI classification system stratifies CLI on the basis of perfusion, extent of wound and superadded infection to provide a composite score which guides further management and predicts final prognosis OBJECTIVE: The aim of the study was to use the SVS WIfI scoring system to predict the need for early revascularization versus early amputation depending on the composite WIfI score at presentation.

METHODOLOGY

This was a retrospective observational study. Data was collected on patients admitted with CLI, in the last 2 years, to calculate composite WIfI score. The WIfI categories according to risk of limb loss were identified with endpoint being major or minor amputation.

RESULTS

Among the 87 patients reviewed, 35 patients (40%) required major amputation, and 29 of those underwent vascular intervention (83%) as part of their care. Median age of the cohort was 72 and 71% were male patients. Comparative analysis between major amputations and minor amputation showed the median score on initial clinical presentation to be 7 in major amputation and 5 in minor amputations (p < 0.0001).

CONCLUSION

The composite WIFi score (a summation of the Wound, Ischaemia, and Infection sub-scores) was a good predictor of need for an amputation WIfI scoring system is a useful tool and should be used early in the management of infected ischaemic limbs.

Outcomes of integrated surgical wound treatment mode based on tibial transverse transport for diabetic foot wound

Background

Diabetic foot ulcer (DFU) is frequently difficult to heal and finally leads to amputation, resulting in high mortality rate in diabetic patients. To date, effective and optimal therapies are still lacking. This study aims to investigate the efficacy of integrated surgical wound treatment (ISWT) mode on diabetic foot wound.

Methods

From January 2021 to December 2021, 13 diabetic foot patients with Wagner grade 3 to 4 were treated with ISWT mode, which combined TTT technique with debridement, induced membrane technique, vacuum sealing drainage (VSD) technique and skin grafting technique. The time of wound healing, the skin temperature at midpoint of dorsum of affected foot (T), visual analogue scale (VAS) score and ankle-brachial index (ABI) was measured before and after surgery. CTA examination of the lower extremity arteries was performed at the end of the cortex transport to evaluate the small arteriolar formation of the lower extremity. The complications occurred in each patient were recorded.

Results

13 patients with age ranging from 45 to 66 years were followed up for 3 to 13 months. All patients healed completely without amputation being performed, no serious complications were found except for one case of nail channel infection. The mean healing time was 25.8 ± 7.8 days, with a range of 17 to 39 days. The mean time of carrying external fixation scaffolds and resuming walking was 71.8 ± 10.0 and 30.8 ± 9.1 days, with a range of 56 to 91 days and 18 to 45 days, respectively. The skin temperature at midpoint of dorsum of affected foot (T), VAS and ABI was all improved significantly at 3 months after surgery. Furthermore, CTA examination showed an increase in the number of lower extremity arteries and a thickening in the size of small arteriolar compared with those of pre-operative, and the collateral circulation of lower extremity was established and interweaved into a network.

Conclusion

Integrated surgical treatment of diabetic foot wound can achieve satisfactory clinical results.

Limb Salvage in Severe Diabetic Foot Infection

Severe diabetic foot infections (DFI) are both limb threatening and life threatening and associated with negative impact on health-related quality of life. Most severe DFIs require surgical intervention, and the goal of treatment should be preservation of limb function in addition to eradication of infection. Minor amputations are required in approximately 40% and major amputations in approximately 20% of patients. Significant risk factors for lower extremity amputation included male gender, smoking, previous amputation, osteomyelitis, peripheral artery disease, retinopathy, severe infections, gangrene, neuroischemic diabetic foot infections, leukocytosis, positive wound cultures, and isolation of gram-negative bacteria.

First Report on the Phenotypic and Genotypic Susceptibility Profiles to Silver Nitrate in Bacterial Strains Isolated from Infected Leg Ulcers in Romanian Patients

Silver-ion-based antiseptics are widely used in treating chronic leg ulcers and, given the emergence of resistance to such compounds, the investigation of silver susceptibility and resistance profiles of pathogenic strains isolated from this type of wound is a topic of great interest. Therefore, in this study, 125 bacterial strains isolated from 103 patients with venous ulcers were investigated to elucidate their susceptibility to silver-nitrate solutions in planktonic and biofilm growth states, and the associated genetic determinants. The isolated strains, both in the planktonic and biofilm growth phases, showed high sensitivity to the standard concentration of 1/6000 silver-nitrate solution. It was noticed that even at concentrations lower than the clinical one (the first 2–3 binary dilutions in the case of planktonic cultures and the first 6–7 binary dilutions in the case of biofilms), the antiseptic solution proved to maintain its antibacterial activity. The phenotypic results were correlated with the genetic analysis, highlighting the presence of silver-resistance genes (sil operon) in only a few of the tested Staphylococcus sp. (especially in S. aureus) strains, Escherichia coli and Pseudomonas aeruginosa strains. These results demonstrate that despite its large use, this antiseptic remains a viable treatment alternative for the management of chronic leg wounds.