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Roberts RHR, Davies-Jones GR, Brock J, Satheesh V, Robertson GAJ. Surgical management of the diabetic foot: The current evidence. World J Orthop 2024; 15:404-417. [DOI: 10.5312/wjo.v15.i5.404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/12/2024] [Accepted: 04/24/2024] [Indexed: 05/15/2024] Open
Abstract
The prevalence of diabetes mellitus and its associated complications, particularly diabetic foot pathologies, poses significant healthcare challenges and economic burdens globally. This review synthesises current evidence on the surgical management of the diabetic foot, focusing on the interplay between neuropathy, ischemia, and infection that commonly culminates in ulcers, infections, and, in severe cases, amputations. The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies, as diabetic foot complications are a leading cause of hospital admissions among diabetic patients, significantly impacting morbidity and mortality rates. This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers, infections, and skeletal pathologies such as Charcot arthropathy, emphasising the critical role of early diagnosis, comprehensive management strategies, and interdisciplinary care in mitigating adverse outcomes. In addressing surgical interventions, this review evaluates conservative surgeries, amputations, and reconstructive procedures, highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies. The integration of advanced diagnostic tools, novel surgical techniques, and postoperative care, including offloading and infection control, are discussed in the context of optimising healing and preserving limb function.
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Affiliation(s)
| | - Gareth Rhys Davies-Jones
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
| | - James Brock
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
| | - Vaishnav Satheesh
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
| | - Greg AJ Robertson
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
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Kwon S, Ha JH, Kim DK, Kim YS, Lim CS, Chang H, Lee JP, Park J. Revisiting metformin therapy for the mitigation of diabetic foot ulcer in patients with diabetic kidney disease from real-world evidence. Int Wound J 2023; 21:e14370. [PMID: 37740678 PMCID: PMC10824619 DOI: 10.1111/iwj.14370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/25/2023] Open
Abstract
Diabetic foot ulcer and diabetic kidney disease are diabetes-related chronic vascular complications that strongly correlate with high morbidity and mortality. Although metformin potentially confers a wound-healing advantage, no well-established clinical evidence supports the benefit of metformin for diabetic foot ulcer. Thus, this study investigated the effect of metformin on diabetic foot ulcer from a large diabetic kidney disease cohort for the first time. This retrospective cohort study enrolled 10 832 patients who visited the nephrology department more than twice at two South Korean tertiary-referral centers between 2001 and 2016. The primary outcome was diabetic foot ulcer events; secondary outcomes included hospitalization, amputation, a composite of amputation or vascular intervention, and Wagner Grade ≥ 3. Multivariate Cox analysis and propensity score matching (PSM) were used to balance baseline intergroup differences between metformin users and non-users. In total, 4748 patients were metformin users, and 6084 patients were metformin non-users. Over a follow-up period of 117.5 ± 66.9 months, the diabetic foot ulcer incidence was 5.2%. After PSM, metformin users showed a lower incidence of diabetic foot ulcer events than metformin non-users (adjusted hazard ratio 0.41; p < 0.001). In a sensitivity analysis of 563 patients with diabetic foot ulcer, metformin usage was associated with lower severity in all four secondary outcomes: hospitalization (adjusted hazard ratio 0.33; p < 0.001); amputation (adjusted hazard ratio 0.44; p = 0.001); composite of amputation or vascular intervention (adjusted hazard ratio 0.47; p < 0.001); and Wagner Grade ≥ 3 (adjusted hazard ratio 0.39; p < 0.001). In conclusion, metformin therapy in patients with diabetic kidney disease can lower diabetic foot ulcer incidence and progression.
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Affiliation(s)
- Soie Kwon
- Department of Internal MedicineChung‐Ang University Heuk‐Seok HospitalSeoulRepublic of Korea
- Department of Clinical Medical SciencesCollege of Medicine, Seoul National UniversitySeoulRepublic of Korea
| | - Jeong Hyun Ha
- Department of Plastic and Reconstructive SurgerySeoul National University HospitalSeoulRepublic of Korea
- Department of Plastic and Reconstructive SurgerySeoul National University Boramae Medical CenterSeoulRepublic of Korea
| | - Dong Ki Kim
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
- Department of Internal MedicineSeoul National University, College of MedicineSeoulRepublic of Korea
| | - Yon Su Kim
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
- Department of Internal MedicineSeoul National University, College of MedicineSeoulRepublic of Korea
| | - Chun Soo Lim
- Department of Internal MedicineSeoul National University, College of MedicineSeoulRepublic of Korea
- Department of Internal MedicineSeoul National University Boramae Medical CenterSeoulRepublic of Korea
| | - Hak Chang
- Department of Plastic and Reconstructive SurgerySeoul National University HospitalSeoulRepublic of Korea
- Department of Plastic and Reconstructive SurgerySeoul National University College of MedicineSeoulRepublic of Korea
| | - Jung Pyo Lee
- Department of Internal MedicineSeoul National University, College of MedicineSeoulRepublic of Korea
- Department of Internal MedicineSeoul National University Boramae Medical CenterSeoulRepublic of Korea
| | - Ji‐Ung Park
- Department of Plastic and Reconstructive SurgerySeoul National University Boramae Medical CenterSeoulRepublic of Korea
- Department of Plastic and Reconstructive SurgerySeoul National University College of MedicineSeoulRepublic of Korea
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Jung SY, Lee MJ, Lee SY. Analysis of the Relationship Between Lower leg Muscle Mass and Preservation of Lower Extremity in Patients with Diabetic Foot Ulcer. INT J LOW EXTR WOUND 2023; 22:503-508. [PMID: 34096804 DOI: 10.1177/15347346211024493] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to determine how the muscle mass of the lower leg affects the preservation of the lower extremities in patients with diabetic foot ulcer. This study analyzed patients with diabetic foot ulcer between January 2014 and June 2018 with a follow-up of at least 2 years. Of these 181 patients whose ulcer is located distal to the metatarsophalangeal joint, which was categorized as grade ≤2 by the Wagner classification were classified into 4 grades: grade 0 (treated without amputation), grade 1 (amputation distal to the metatarsophalangeal joint), grade 2 (Ray, transmetatarsal, Lisfranc, and Chopart amputation), and grade 3 (Syme, below-knee, and above-knee amputation) according to the final amputation degree. The muscles of the lower leg were classified into 4 compartments: anterior, lateral, deep posterior, and superficial posterior. The cross-sectional area and attenuation to estimate the muscle volume and density were measured at the axial image of computed tomography (CT) angiography. No significant differences were observed in the sex ratio and mean age among the grades (P = .966 and .962). The cross-sectional area of the anterior, lateral, and posterior compartments demonstrated no significant differences, but that of the superficial posterior compartment exhibited significant differences among the grades (P < .001). Moreover, the attenuation of the anterior, lateral, and deep posterior compartments showed no significant differences, but that of the posterior compartment showed significant differences among the grades (P = .003). The muscle mass of the superficial posterior compartment of the lower leg could be a good indicator of the preservation of the lower extremity in patients with diabetic foot ulcer. Therefore, a strengthening exercise for the triceps surae and plantaris muscles in the early stage could help preserve as much of the lower extremities as possible.
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Affiliation(s)
- Sung Y Jung
- Department of Orthopedic Surgery, College of Medicine, Dong-A University, Busan, Korea
| | - Myoung J Lee
- Department of Orthopedic Surgery, College of Medicine, Dong-A University, Busan, Korea
| | - Sang Y Lee
- Department of Orthopedic Surgery, College of Medicine, Dong-A University, Busan, Korea
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Maeshige N, Hayashi H, Kawabe N, Imaoka S, Sakaki S, Matsumoto J, Kondo E, Ishii T, Kiyota N, Furukawa M, Terashi H, Sonoda Y. Effect of Early Rehabilitation on Walking Independence and Health-Related Quality of Life in Patients With Chronic Foot Wounds: A Multicenter Randomized Clinical Trial. INT J LOW EXTR WOUND 2023:15347346231187178. [PMID: 37448201 DOI: 10.1177/15347346231187178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
Rehabilitation is usually provided to patients with chronic foot wounds (CFWs) after surgery. This study aimed to assess whether early postoperative rehabilitation could maintain walking independence in hospitalized patients with CFWs. This single-blind, randomized clinical trial was performed between September 10, 2018 and March 2019, involving 60 patients who underwent both surgical procedures and rehabilitation. Participants were randomly allocated into the early rehabilitation (EG, n = 30) or the control (CG, n = 30) groups. EG received early rehabilitation immediately after surgery, while CG received late rehabilitation after wound closure. Both groups received rehabilitation sessions 5 times per week until discharge. The primary outcome was walking independence, measured via Functional Independence Measure (FIM)-gait scores. Secondary outcomes included health-related quality of life (HRQoL) using EuroQol 5 dimensions 5-level (EQ-5D-5L) and the presence of rehabilitation-related adverse events, including dehiscence of wounds and falls. Differences in intervention timing effects were analyzed using nonparametric split-plot factorial design analysis, including Fisher's exact test, Mann-Whitney U test, and Wilcoxon signed-rank test (P < .05). Out of the 60 participants, 53 patients completed the discharge follow up. Three participants (10.0%) from the EG and 4 (13.3%) from the CG dropped out due to postoperative complications unrelated to rehabilitation intervention. No rehabilitation-related adverse events were found. Participants in the EG maintained greater FIM-gait scores during hospitalization than the CG (difference, -1; P = .0001), with a difference of 0 (P = .109) at discharge. EQ-5D-5L significantly improved in both groups (EG: difference, 0.13 [P = .014], CG: difference, 0.17 [P = .0074]). The EG intervention was associated more with maintaining walking independence at discharge than CG intervention. Postoperative rehabilitation improved HRQoL without adverse events, indicating that clinicians should recommend early rehabilitation for patients with CFW to enhance walking independence.
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Affiliation(s)
- Noriaki Maeshige
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Hyogo, Japan
| | - Hisae Hayashi
- Faculty of Health and Medical Sciences, Aichi Shukutoku University, Nagakute, Aichi, Japan
| | - Nobuhide Kawabe
- Faculty of Makuhari Human Care, Tohto University, Makuhari, Chiba, Japan
| | - Shinsuke Imaoka
- Department of Rehabilitation, Oita Oka Hospital, Oita, Oita, Japan
| | - Satoko Sakaki
- Department of Rehabilitation, Kasukabe Chuo General Hospital, Kasukabe, Saitama, Japan
| | - Junichi Matsumoto
- Department of Rehabilitation, Kasukabe Chuo General Hospital, Kasukabe, Saitama, Japan
| | - Eriko Kondo
- Department of Rehabilitation Medicine, Nagoya Kyoritsu Hospital, Nagoya, Aichi, Japan
| | - Tatsuya Ishii
- Department of Rehabilitation Medicine, Nagoya Kyoritsu Hospital, Nagoya, Aichi, Japan
| | - Naruaki Kiyota
- Department of Rehabilitation Medicine, Nagoya Kyoritsu Hospital, Nagoya, Aichi, Japan
| | | | - Hiroto Terashi
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuma Sonoda
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Hyogo, Japan
- Advanced Research Center for Well-being, Kobe University, Kobe, Hyogo, Japan
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Berger LE, Spoer DL, Huffman SS, Khayat E, Lava CX, Akbari CM, Atves JN, Steinberg JS, Attinger CE, Evans KK. A Comparative Analysis of Functional and Patient-Reported Outcomes Following Lisfranc and Chopart Amputations in High-Risk Limb Salvage Patients. J Foot Ankle Surg 2023; 62:S1067-2516(23)00117-5. [PMID: 37160203 DOI: 10.1053/j.jfas.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/21/2023] [Accepted: 04/30/2023] [Indexed: 05/11/2023]
Abstract
Midfoot amputations provide an opportunity for limb salvage through preservation of a weightbearing limb. However, the longevity of midfoot amputations is threatened by restrictions in surface area and risks of skin breakdown. To better inform decisions surrounding the level of amputation, we sought to compare outcomes of high-risk individuals who underwent Lisfranc or Chopart amputations. A single-center retrospective cohort study was performed from November 2013 to September 2022 of adult patients who underwent Lisfranc or Chopart amputations. Patients were stratified into cohorts based on the amputation type. Outcomes included postoperative rates of re-amputation, functional status, mortality and patient-reported outcome measures in the form of Lower Extremity Functional Scale scores. Sixty-six patients were identified; of which, 45 underwent Lisfranc amputation, and 21 underwent Chopart amputation. Median Charlson Comorbidity Index was 7, signifying a substantial comorbidity burden. By median follow-up of 14 (Interquartile range: 28) months, 31 patients (36%) progressed to higher-level amputation, and most patients were ambulatory (n = 38, 58%). Overall rates of re-amputation, ambulatory status, and mortality were comparable between groups. Re-amputation to another midfoot amputation was more common among the Lisfranc cohort (n = 16, 36% vs n = 1, 5%), whereas re-amputation to BKA was more prevalent among the Chopart cohort (Chopart: n = 7, 33% vs Lisfranc: n = 7, 16%; p = .011). Average Lower Extremity Functional Scale scores were similar between groups and corresponded to a maximal function of 48%. Lisfranc and Chopart amputations have the potential to be efficacious limb salvage options in high-risk patient populations in conjunction with intraoperative biomechanical optimization and optimal preoperative patient selection.
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Affiliation(s)
- Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, DC; Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Elias Khayat
- Georgetown University School of Medicine, Washington, DC
| | | | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital; Washington, DC
| | - Jayson N Atves
- Department of Podiatric Surgery, MedStar Georgetown University Hospital; Washington, DC
| | - John S Steinberg
- Department of Podiatric Surgery, MedStar Georgetown University Hospital; Washington, DC
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, DC
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, DC.
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Kavarthapu V, Giddie J, Kommalapati V, Casey J, Bates M, Vas P. Evaluation of Adjuvant Antibiotic Loaded Injectable Bio-Composite Material in Diabetic Foot Osteomyelitis and Charcot Foot Reconstruction. J Clin Med 2023; 12:jcm12093239. [PMID: 37176679 PMCID: PMC10179343 DOI: 10.3390/jcm12093239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023] Open
Abstract
The management of diabetic foot osteomyelitis (DFO) is extremely challenging with high amputation rates reported alongside a five-year mortality risk of more than fifty percent. We describe our experience in using adjuvant antibiotic-loaded bio-composite material (Cerament) in the surgical management of DFO and infected Charcot foot reconstruction. We undertook a retrospective evaluation of 53 consecutive patients (54 feet) who underwent Gentamicin or Vancomycin-loaded Cerament application during surgery. The feet were categorised into two groups: Group 1, with infected ulcer and DFO, managed with radical debridement only (n = 17), and Group 2, requiring reconstruction surgery for infected and deformed Charcot foot. Group 2 was further subdivided into 2a, with feet previously cleared of infection and undergoing a single-stage reconstruction (n = 19), and 2b, with feet having an active infection managed with a two-stage reconstruction (n = 18). The mean age was 56 years (27-83) and 59% (31/53) were males. The mean BMI was 30.2 kg/m2 (20.8-45.5). Foot ulcers were present in 69% (37/54) feet. At a mean follow-up of 30 months (12-98), there were two patients lost to follow up and the mortality rate was 11% (n = 5). The mean duration of post-operative systemic antibiotic administration was 20 days (4-42). Thirteen out of fifteen feet (87%) in group 1 achieved complete eradication of infection. There was a 100% primary ulcer resolution, 100% limb salvage and 76% bony union rate within Group 2. However, five patients, all in group 2, required reoperations due to problems with bone union. The use of antibiotic-loaded Cerament resulted in a high proportion of patients achieving infection clearance, functional limb salvage and decrease in the duration of postoperative antibiotic therapy. Larger, preferably randomised, studies are required to further validate these observations.
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Affiliation(s)
- Venu Kavarthapu
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Jasdeep Giddie
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Varun Kommalapati
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Joanne Casey
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Maureen Bates
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Prashanth Vas
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
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van der Wal GE, Dijkstra PU, Geertzen JH. Lisfranc and Chopart amputation: A systematic review. Medicine (Baltimore) 2023; 102:e33188. [PMID: 36897730 PMCID: PMC9997832 DOI: 10.1097/md.0000000000033188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/14/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Lisfranc and Chopart amputations are historically controversial procedures. To obtain evidence for the pros and cons we performed a systematic review to analyze wound healing, the need for re-amputation at a higher level, and ambulation after a Lisfranc or Chopart amputation. METHODS A literature search was performed in 4 databases (Cochrane, Embase, Medline, and PsycInfo), using database-specific search strategies. Reference lists were studied to include relevant studies that were missed in the search. Of the 2881 publications found, 16 studies could be included in this review. Excluded publications concerned editorials, reviews, letters to the editor, no full text available, case reports, not meeting the topic, and written in a language other than English, German, or Dutch. RESULTS Failed wound healing occurred in 20% after Lisfranc amputation, in 28% after modified Chopart amputation, and 46% after conventional Chopart amputation. After Lisfranc amputation, 85% of patients were able to ambulate without prosthesis for short distances, and after modified Chopart 74%. After a conventional Chopart amputation, 26% (10/38) had unlimited household ambulation. CONCLUSIONS The need for re-amputation because wound healing problems occurred most frequently after conventional Chopart amputation. All 3 types of amputation levels do, however, provide a functional residual limb, with the remaining ability to ambulate without prosthesis for short distances. Lisfranc and modified Chopart amputations should be considered before proceeding to a more proximal level of amputation. Further studies are needed to identify patient characteristics to predict favorable outcomes of Lisfranc and Chopart amputations.
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Affiliation(s)
- Gesiena E. van der Wal
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
| | - Pieter U. Dijkstra
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, The Netherlands
| | - Jan H.B. Geertzen
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
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Glousman BN, Cragon R, Steinberg JS, Evans KK, Attinger CE, Kiguchi MM, Tefera E, Akbari CM. Presence of a patent pedal arch is the primary predictor of transmetatarsal amputation healing and limb salvage. J Vasc Surg 2023; 77:1487-1494. [PMID: 36717038 DOI: 10.1016/j.jvs.2023.01.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/17/2023] [Accepted: 01/22/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Transmetatarsal amputation (TMA) is a durable and important functional limb salvage option. We have presented our results in identifying the angiographic predictors of TMA healing using single-institution retrospective data. METHODS Consecutive patients within our institution who had undergone TMA and lower extremity arteriography from 2012 to 2020 were included. Patients whose TMA had healed were compared with those whose TMA had not healed. Using pre- and perioperative patient factors, in addition to the Global Limb Anatomic Staging System (GLASS) and evaluation of the tibial runoff vessels, multivariate analysis was used to define the predictors of TMA healing at 30 days and 1 year. For those patients who had undergone an intervention after TMA, including repeat interventions, the postintervention GLASS stage was calculated. All patients were followed up by the vascular surgeon using standard ultrasound surveillance and clinical examinations. Once the predictors had been identified, an analysis was performed to correlate the 30-day and 1-year limb salvage rates. RESULTS A total of 89 patients had met the inclusion criteria for the study period. No difference was found in the GLASS femoropopliteal or infrapopliteal stages for those with a healed TMA and those without. After multivariate regression analysis, the presence of a patent pedal arch vs a nonintact arch had a 5.5 greater odds of TMA healing at 30 days but not at 1 year. Additionally, the presence of a patent arch was strongly associated with limb salvage at both 30 days (86% vs 49%; P < .01) and 1 year (79% vs 49%; P < .01). CONCLUSIONS In the present series of patients who had undergone TMA and arteriography, with appropriate GLASS staging, we found patency of the pedal arch was a significant predictor of healing and limb salvage. The GLASS femoropopliteal and infrapopliteal stages did not predict for TMA healing.
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Affiliation(s)
- Brandon N Glousman
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC.
| | - Robert Cragon
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - John S Steinberg
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | | | - Misaki M Kiguchi
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Eshetu Tefera
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
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Hong CC, Saha S, Pearce CJ. Does a shorter residual first metatarsal length after first ray amputation in diabetic patients leads to poorer outcomes - A risk factor study. Foot Ankle Surg 2023; 29:228-232. [PMID: 36746697 DOI: 10.1016/j.fas.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 01/08/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND The first ray plays a vital role in the normal function of the foot and the gait cycle where in its absence can lead to abnormal changes in weight distribution to the residual first metatarsal stump and lesser metatarsals with predisposition to developing lesser toe deformities reulcerations and reamputations particularly in diabetic patients. This study aims to characterise the outcomes after first ray amputation and its associated risk factors with focus on the impact of residual first metatarsal length. METHODS All diabetic patients with first ray amputations from January 2012 to December 2016 were reviewed. Residual first metatarsal length was measured using postoperative radiographs. Risk factors for outcomes such as readmission, reulceration and/or reamputation, transfer ulceration and/or amputation of lesser toes, proximal amputations, ulcer-free duration (UFD) and mortality were analysed using bivariate logistic/linear regression followed by multiple logistic/linear regression models adjusting for confounding factors. RESULTS Among 89 patients with first ray amputations, 65.3 % needed readmission for further treatment. Although only 10.1 % had reulceration at the first ray which all led to reamputation, there were 56.2 % with transfer ulceration and 40.4 % with transfer amputation of the lesser toes in this cohort. The prevalence of transmetatarsal amputation was 18 % and proximal amputations at 12.4 % while the average UFD was 27 months. Mortality rate was 31.5 % with an average of 3-year survival. Preservation of the first metatarsal length via metatarsophalangeal joint disarticulation independently reduced likelihood of readmissions and residual metatarsal length of > one third when compared to < one third after first ray amputations had lower likelihood of transfer amputation of lesser toes. CONCLUSION First ray amputation in diabetic patients leads to significant morbidities and mortality. Preservation of the residual first metatarsal length independently reduced the likelihood of readmissions and transfer amputation to the lesser toes.
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Affiliation(s)
- Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore, Singapore.
| | - Soura Saha
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore, Singapore.
| | - Christopher Jon Pearce
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore, Singapore.
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Abstract
PURPOSE Lower extremity amputation resulting from diabetic foot ulcer, with neuropathic and/or ischemic etiologies, remains a devastating and costly complication of diabetes mellitus. This study evaluated changes in care delivery of diabetic foot ulcer patients during the COVID-19 pandemic. A longitudinal assessment evaluating the ratio of major lower extremity amputation to minor lower extremity amputations after implementation of novel strategies to combat access restrictions was compared to the pre-COVID-19 era. METHODS The ratio of major to minor lower extremity amputation (i.e. the high-to-low ratio) was assessed at two academic institutions, the University of Michigan, and University of Southern California, in a population of patients with diabetes who had direct access to multidisciplinary foot care clinics in the 2 years prior to the pandemic and the first 2 years of the COVID-19 pandemic. RESULTS Patient characteristics and volumes including patients with diabetes and those with a diabetic foot ulcer were similar between eras. In addition, inpatient diabetic foot-related admissions were similar, but were suppressed by government shelter in placed mandates and subsequent COVID-19 variants surges (e.g. delta, omicron). In the control group, the Hi-Lo ratio increased every 6 months by an average of 11.8%. Meanwhile, following STRIDE implementation during the pandemic, the Hi-Lo ratio reduced by (-)11% (p < 0.001) and doubled limb salvage efforts as compared to the baseline era. The reduction of the Hi-Lo ratio was not influenced significant by patient volumes or inpatient admissions for foot infections. CONCLUSION These findings signify the importance of podiatric care in the at-risk diabetic foot population. Through strategic planning and rapid implementation of at-risk diabetic foot ulcer triage, multidisciplinary teams were able to maintain accessible care during the pandemic which resulted in a reduction of amputations. Furthermore, this manuscript highlights the value of the Hi-Lo ratio as an indicator of institutional limb salvage efforts.
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Affiliation(s)
| | - Laura Shin
- Division of Clinical Surgery, Department of Vascular Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Gimenez AR, Lazo D, Chade S, Fioravanti A, Colicchio O, Alvarez D, Junior E, Raj S, Abu-Ghname A, Maricevich M. Extracorporeal Pedicles for Free Flap Reconstruction in Diabetic Lower Extremity Wounds. Arch Plast Surg 2022; 49:782-784. [PMCID: PMC9747274 DOI: 10.1055/s-0042-1758635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 07/08/2022] [Indexed: 12/15/2022] Open
Abstract
Diabetic foot ulcers are a severe complication of diabetes, and their management requires a multidisciplinary approach for optimal management. When treating these ulcers, limb salvage remains the ultimate goal. In this article, we present the “hanging” free flap for the reconstruction of chronic lower extremity diabetic ulcers. This two-staged approach involves standard free flap harvest and inset; however, following inset the “hanging” pedicle is covered within a skin graft instead of making extraneous incisions within the undisturbed soft tissues or tunnels that can compress the vessels. After incorporation, a second-stage surgery is performed in 4 to 6 weeks which entails pedicle division, flap inset revision, and end-to-end reconstruction of the recipient vessel. Besides decreasing the number of incisions on diabetic patients, our novel technique utilizing the “hanging” pedicle simplifies flap monitoring and inset and allows reconstruction of recipient vessels to reestablish distal blood flow.
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Affiliation(s)
- Alejandro R. Gimenez
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | | | | | | | | | | | - Sarth Raj
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Marco Maricevich
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas,Address for correspondence Marco Maricevich, MD Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine1977 Butler Blvd. Suite E6.100Houston, TX 77030
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12
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Chen Y, Ding X, Zhu Y, Jia Z, Qi Y, Chen M, Lu J, Kuang X, Zhou J, Su Y, Zhao Y, Lu W, Zhao J, Hua Q. Effect of tibial cortex transverse transport in patients with recalcitrant diabetic foot ulcers: A prospective multicenter cohort study. J Orthop Translat 2022; 36:194-204. [PMID: 36263383 DOI: 10.1016/j.jot.2022.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/05/2022] [Accepted: 09/05/2022] [Indexed: 12/18/2022] Open
Abstract
Background Management of recalcitrant diabetic foot ulcer (DFU) remains difficult. Distraction osteogenesis mediates new bone formation and angiogenesis in the bone itself and the surrounding tissues. Recently it was reported that tibial cortex transverse transport (TTT) was associated with neovascularization and increased perfusion at the foot in patients with recalcitrant DFUs and facilitated healing and limb salvage. However, the findings were from several single-center studies with relatively small populations, which need to be confirmed in multicenter cohort studies with relatively large populations. Furthermore, the effect of this technique on patient's health-related quality of life is still unclear. Methods We treated patients with recalcitrant (University of Texas wound grading system 2-C to 3-D and not responding to prior routine conservative and surgical treatments for at least 8 weeks) DFUs from seven centers using TTT (a 5 cm × 1.5 cm corticotomy followed by 4 weeks of medial and lateral distraction) between July 2016 and June 2019. We analyzed ulcer healing, major amputation, recurrence, health-related quality of life (physical and mental component summary scores), and complications in the 2-year follow-up. Foot arterial and perfusion changes were evaluated using computed tomography angiography and perfusion imaging 12 weeks postoperatively. Results A total of 1175 patients were enrolled. Patients who died (85, 7.2%) or lost to follow-up (18, 1.7%) were excluded, leaving 1072 patients for evaluation. Most of the patients were male (752, 70.1%) and with a mean age of 60.4 ± 9.1 years. The mean ulcer size was 41.0 ± 8.5 cm2 and 187 (16.6%) ulcers extended above the ankle. During the follow-up, 1019 (94.9%) patients healed in a mean time of 12.4 ± 5.6 weeks, 53 (4.9%) had major amputations, and 33 (3.1%) experienced recurrences. Compared to preoperatively, the patients had higher physical (26.2 ± 8.3 versus 41.3 ± 10.6, p = 0.008) and mental (33.6 ± 10.7 versus 45.4 ± 11.3, p = 0.031) component summary scores at the 2-year follow-up. Closed tibial fracture at the corticotomy site was found in 8 (0.7%) patients and was treated using external fixation and healed uneventfully. There were 23 (2.1%) patients who had pin site infections and were treated successfully with dressing changes. Compared to preoperatively, the patients had more small arteries and higher foot blood flow (8.1 ± 2.2 versus 28.3 ± 3.9 ml/100 g/min, p = 0.003) and volume (1.5 ± 0.3 versus 2.7 ± 0.4 ml/100 g, p = 0.037) 12 weeks postoperatively. Conclusion TTT promotes healing, limb salvage, and health-related quality of life in patients with recalcitrant DFUs as demonstrated in this multicenter cohort study. The surgical procedure was simple and straightforward and the complications were few and minor. The effect of this technique was associated with neovascularization and improved perfusion at the foot mediated by the cortex distraction. The findings are required to confirm in randomized controlled trials.The Translational Potential of this Article: TTT can be used as an effective treatment in patients with recalcitrant DFUs. The mechanism is associated with neovascularization and consequently increased perfusion in the foot after operation.
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Cook HR, Cates NK, Kennedy CJ, Tefera E, Popovsky D, Delijani K, Kim PJ, Attinger CE, Steinberg JS. Risks Factors Associated With Major Lower Extremity Amputation After Vertical Contour Calcanectomy. J Foot Ankle Surg 2022; 61:1046-1051. [PMID: 35168902 DOI: 10.1053/j.jfas.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/22/2020] [Accepted: 01/10/2022] [Indexed: 02/03/2023]
Abstract
The primary aim of the study is to determine risks for major lower extremity amputation after undergoing Vertical Contour Calcanectomy. Subanalysis was performed comparing patients who underwent Vertical Contour Calcanectomy who were fully ambulatory to those who were partially or nonambulatory postoperatively. Within the cohort of 63 patients included in the Vertical Contour Calcanectomy 85.71% (54/63) of patients had diabetes mellitus, 53.97% (34/63) had peripheral arterial disease, and 19.05% (12/63) had Charcot Neuroarthropathy. Multivariate logistic regression, found that (1) patients that underwent primary closure at the time of the Vertical Contour Calcanectomy, were 79.9% more likely (odds ratio [OR] 0.20; 95% confidence interval [CI] 0.04-0.96) to have limb salvage and that (2) female patients were 85.4% less likely compared to male patients (OR 0.15; 95% CI 0.02-0.99) to undergo major lower extremity amputation. Patients with coronary artery disease were 5.2 times more likely (OR 5.18; 95% CI 1.120-23.94) and patients that were nonambulatory preoperatively, were 10.3 times more likely (OR 10.28; 95% CI 1.60-66.26), to be partially or nonambulatory after Vertical Contour Calcanectomy. Primary closure at time of Vertical Contour Calcanectomy significantly decreases the risk of major lower extremity amputation, and diminished preoperative ambulatory status as well as coronary artery disease makes it less likely that patients return to full ambulation after Vertical Contour Calcanectomy.
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Affiliation(s)
- Helene R Cook
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Nicole K Cates
- Limb Preservation and Deformity Correction Fellow, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Christopher J Kennedy
- MedStar Georgetown University Hospital Diabetic Limb Salvage Fellow, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Eshetu Tefera
- Department of Biostatistician and Biomedical Informatics, MedStar Health Research Institute, Washington, DC
| | - Daniel Popovsky
- Medical Student, Georgetown University Medical School, Washington, DC
| | - Kevin Delijani
- Medical Student, Georgetown University Medical School, Washington, DC
| | - Paul J Kim
- Attending Physician, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Christopher E Attinger
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - John S Steinberg
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC.
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Abstract
BACKGROUND Diabetic foot osteomyelitis (DFO) often leads to amputations in the lower extremity. Data on the influence of the initial anatomical DFO localization on ultimate major amputation are limited. METHODS In this retrospective analysis, 583 amputation episodes in 344 patients (78 females, 266 males) were analyzed. All received a form of amputation in combination with antibiotic therapy. A multivariate logistic regression analysis with the primary outcome "major amputation" defined as an amputation above the ankle joint was performed. The association of risk factors including location of DFO, coronary artery disease, peripheral artery disease, neuropathy, nephropathy, and Charcot neuro-osteoarthropathy was analyzed. RESULTS Among 583 episodes, DFO was located in the forefoot in 512 (87.8%), in the midfoot in 43 (7.4%), and in the hindfoot in 28 episodes (4.8%). Overall, 53 of 63 (84.1%) major amputations were performed because of DFO in the setting of peripheral artery disease as primary indication. Overall, limb loss occurred in 6.1% (31/512) of forefoot, 20.9% (9/43) of midfoot, and 46.4% (13/28) of hindfoot DFO. Among these, 22 (41.5%) were performed as the primary treatment, whereas 31 (58.5%) followed previously failed minor amputations. Among this latter group of secondary major amputations, the DFO was localized to the forefoot in 23 of 583 (3.9%), the midfoot in 4 of 583 (0.7%) and the hindfoot in 4 of 583 (0.7%). In multivariate logistic regression analysis, initial hindfoot localization was a significant factor (P < .05), whereas peripheral artery disease, smoking, and a midfoot DFO were not found to be risk factors. CONCLUSION In our retrospective series, the frequency of limb loss in DFO increased with more proximal initial foot DFO lesions, with almost half of patients losing their limbs with a hindfoot DFO. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Elin Winkler
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland,Elin Winkler, MD, Department of
Orthopedics, Balgrist University Hospital, Forchstrasse 340, Zürich, 8008,
Switzerland.
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Nicola Krähenbühl
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Ilker Uçkay
- Infectiology, Unit for Clinical and
Applied Research and Infectiology, Balgrist University Hospital, Zurich,
Switzerland
| | - Felix W. A. Waibel
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
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15
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Pereira PF, Silva MR, Simão RS, Negrão P, Sousa A, Neves N. Total calcanectomy in calcaneal osteomyelitis: An alternative to major amputation. Foot (Edinb) 2022; 51:101896. [PMID: 35290842 DOI: 10.1016/j.foot.2021.101896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 10/20/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hindfoot ulcers associated with chronic calcaneus osteomyelitis are very difficult to manage and many patients need a limb amputation for resolution. Total calcanectomy can be a salvage procedure for these patients. The purpose of this study is to present our results of total calcanectomy. METHODS Retrospective analysis of six patients undergoing total calcanectomy at our institution between 2008 and 2019. Patient data and ambulatory status were analyzed. RESULTS In 4 of the 6 patients, infection control and wound closure was achieved with total calcanectomy with follow-up ranging from 1 to 12 years. The 4 patients maintain walking ability. Two major complications: an early death caused by a respiratory infection and a below the knee amputation due to recurrence of the foot infection. CONCLUSION Total calcanectomy is an useful procedure for limb salvage in foot ulcers with chronic calcaneus osteomyelitis.
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Affiliation(s)
| | - Manuel Ribeiro Silva
- Orthopedics Department, Centro Hospitalar e Universitário de São João, Porto, Portugal; Surgery and Physiology Department, Faculty of Medicine, University of Porto, Porto, Portugal; CUF Porto Hospital, Porto, Portugal; i3S - Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal; INEB - Instituto Nacional de Engenharia Biomédica, University of Porto, Porto, Portugal
| | - Ricardo São Simão
- Orthopedics Department, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Pedro Negrão
- Orthopedics Department, Centro Hospitalar e Universitário de São João, Porto, Portugal; Surgery and Physiology Department, Faculty of Medicine, University of Porto, Porto, Portugal; CUF Porto Hospital, Porto, Portugal
| | - António Sousa
- Orthopedics Department, Centro Hospitalar e Universitário de São João, Porto, Portugal; Surgery and Physiology Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Nuno Neves
- Orthopedics Department, Centro Hospitalar e Universitário de São João, Porto, Portugal; Surgery and Physiology Department, Faculty of Medicine, University of Porto, Porto, Portugal; CUF Porto Hospital, Porto, Portugal; i3S - Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal; INEB - Instituto Nacional de Engenharia Biomédica, University of Porto, Porto, Portugal
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16
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Ruemenapf G, Morbach S, Sigl M. Therapeutic Alternatives in Diabetic Foot Patients without an Option for Revascularization: A Narrative Review. J Clin Med 2022; 11:jcm11082155. [PMID: 35456247 PMCID: PMC9032488 DOI: 10.3390/jcm11082155] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 12/30/2022] Open
Abstract
Background: The healing of foot wounds in patients with diabetes mellitus is frequently complicated by critical limb threatening ischemia (neuro-ischemic diabetic foot syndrome, DFS). In this situation, imminent arterial revascularization is imperative in order to avoid amputation. However, in many patients this is no longer possible (“too late”, “too sick”, “no technical option”). Besides conservative treatment or major amputation, many alternative methods supposed to decrease pain, promote wound healing, and avoid amputations are employed. We performed a narrative review in order to stress their efficiency and evidence. Methods: The literature research for the 2014 revision of the German evidenced-based S3-PAD-guidelines was extended to 2020. Results: If revascularization is impossible, there is not enough evidence for gene- and stem-cell therapy, hyperbaric oxygen, sympathectomy, spinal cord stimulation, prostanoids etc. to be able to recommend them. Risk factor management is recommended for all CLTI patients. With appropriate wound care and strict offloading, conservative treatment may be an effective alternative. Timely amputation can accelerate mobilization and improve the quality of life. Conclusions: Alternative treatments said to decrease the amputation rate by improving arterial perfusion and wound healing in case revascularization is impossible and lack both efficiency and evidence. Conservative therapy can yield acceptable results, but early amputation may be a beneficial alternative. Patients unfit for revascularization or major amputation should receive palliative wound care and pain therapy. New treatment strategies for no-option CLTI are urgently needed.
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Affiliation(s)
- Gerhard Ruemenapf
- Vascular Center Oberrhein Speyer-Mannheim, Department of Vascular Surgery, Diakonissen-Stiftungs-Krankenhaus, 67346 Speyer, Germany
- Correspondence: ; Tel.: +49-6232-22-1955; Fax: +49-6232-22-1994
| | - Stephan Morbach
- Department of Diabetology und Angiology, Marienkrankenhaus, 59494 Soest, Germany;
| | - Martin Sigl
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site, 68199 Mannheim, Germany;
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17
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Fan KL, Bekeny JC, Kennedy CJ, Zolper EG, Steinberg JS, Attinger CE, Evans KK, DeLia D. A Focus on Amputation Level: Factors Preventing Length Preservation in the National Inpatient Sample. J Am Podiatr Med Assoc 2022; 112:20-028. [PMID: 35324459 DOI: 10.7547/20-028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Diabetic lower-extremity disease is the primary driver of mortality in patients with diabetes. Amputations at the forefoot or ankle preserve limb length, increase function, and, ultimately, reduce deconditioning and mortality compared with higher-level amputations, such as below-the-knee amputations (BKAs). We sought to identify risk factors associated with amputation level to understand barriers to length-preserving amputations (LPAs). METHODS Diabetic lower-extremity admissions were extracted from the 2012-2014 National Inpatient Survey using ICD-9-CM diagnosis codes. The main outcome was a two-level variable consisting of LPAs (transmetatarsal, Syme, and Chopart) versus BKAs. Logistic regression analysis was used to determine contributions of patient- and hospital-level factors to likelihood of undergoing LPA versus BKA. RESULTS The study cohort represented 110,355 admissions nationally: 42,375 LPAs and 67,980 BKAs. The population was predominantly white (56.85%), older than 50 years (82.55%), and male (70.38%). On multivariate analysis, living in an urban area (relative risk ratio [RRR] = 1.48; P < .0001) and having vascular intervention in the same hospital stay (RRR = 2.96; P < .0001) were predictive of LPA. Patients from rural locations but treated in urban centers were more likely to receive BKA. Minorities were more likely to present with severe disease, limiting delivery of LPAs. A high Elixhauser comorbidity score was related to BKA receipt. CONCLUSIONS This study identifies delivery biases in amputation level for patients without access to large, urban hospitals. Rural patients seeking care in these centers are more likely to receive higher-level amputations. Further examination is required to determine whether earlier referral to multidisciplinary centers is more effective at reducing BKA rates versus satellite centers in rural localities.
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Affiliation(s)
- Kenneth L Fan
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jenna C Bekeny
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher J Kennedy
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Elizabeth G Zolper
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - John S Steinberg
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher E Attinger
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Derek DeLia
- *Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC.,†MedStar Health Research Institute, Hyattsville, MD
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Deldar R, Abu El Hawa AA, Haffner ZK, Higgins JP, Katz RD, Attinger CE, Evans KK. Achieving Functional Outcomes after Surgical Management of Catastrophic Vasopressor-induced Limb Ischemia. Plast Reconstr Surg Glob Open 2022; 10:e4175. [PMID: 35265449 PMCID: PMC8901208 DOI: 10.1097/gox.0000000000004175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/06/2022] [Indexed: 12/02/2022]
Abstract
Vasopressor-induced limb ischemia is an unfortunate complication that can occur in patients treated for septic shock. Current literature lacks surgical treatment recommendations for this condition, besides amputation. We describe various reconstructive surgeries and functional outcomes in patients treated surgically for vasopressor-induced limb ischemia.
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19
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Tram NK, Chou TH, Patel S, Ettefagh LN, Go MR, Atway SA, Stacy MR. Novel Application of 18F-NaF PET/CT Imaging for Evaluation of Active Bone Remodeling in Diabetic Patients With Charcot Neuropathy: A Proof-of-Concept Report. Front Med (Lausanne) 2022; 9:795925. [PMID: 35252240 PMCID: PMC8896741 DOI: 10.3389/fmed.2022.795925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Charcot neuropathic osteoarthropathy (CN) is a serious and potentially limb-threatening complication for patients with diabetes mellitus and peripheral arterial disease. In recent decades, nuclear medicine-based approaches have been used for non-invasive detection of CN; however, to date, a positron emission tomography (PET) radionuclide specifically focused on targeted imaging of active bone remodeling has not been explored or validated for patients with CN. The radionuclide 18F-sodium fluoride (NaF) has historically been used as a bone imaging probe due to its high sensitivity for targeting hydroxyapatite and bone turnover, but has not been applied in the context of CN. Therefore, the present study focused on novel application of 18F-NaF PET/computed tomography (CT) imaging to three clinical cases of CN to evaluate active bone remodeling at various time courses of CN. PET/CT imaging in all 3 cases demonstrated focal uptake of 18F-NaF in the bones of the feet afflicted with CN, with bone retention of 18F-NaF persisting for up to 5 years following surgical reconstruction of the foot in two cases. On a group level, 18F-NaF bone uptake in the CN foot was significantly higher compared to the healthy, non-CN foot (p = 0.039). 18F-NaF PET/CT imaging may provide a non-invasive tool for monitoring active bone remodeling in the setting of CN, thereby offering novel opportunities for tracking disease progression and improving treatment and surgical intervention.
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Affiliation(s)
- Nguyen K. Tram
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Ting-Heng Chou
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Surina Patel
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Laila N. Ettefagh
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Michael R. Go
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Said A. Atway
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Mitchel R. Stacy
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
- *Correspondence: Mitchel R. Stacy
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20
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Cook H, Kennedy C, Delijani K, Popovsky D, Elmarsafi T, Zarick C, Attinger C, Steinberg J. Early Clinical, Functional, and Mortality Outcomes for Heel Ulcers Treated With a Vertical Contour Calcanectomy. J Foot Ankle Surg 2022; 61:117-122. [PMID: 34330617 DOI: 10.1053/j.jfas.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/15/2021] [Accepted: 06/26/2021] [Indexed: 02/03/2023]
Abstract
Heel ulcerations are common complications seen in patients suffering from chronic conditions such as diabetes mellitus, peripheral vascular disease, and in bed ridden patients. When these systemic pathologies lead to heel ulcers, an increased risk of calcaneal osteomyelitis often significantly limits the benefits of conventional therapeutic interventions and increases risk of major lower extremity amputation. The Vertical Contour Calcanectomy (VCC) is a novel surgical procedure specific for the surgical management of these complex and often recalcitrant heel ulcerations. The VCC was described as a reproducible procedure in which wide excision of both the soft tissue ulceration as well as defined bone cuts of the calcaneus allows for decreased bioburden and in many cases, for primary soft tissue closure. The present study describes the outcomes related to the VCC and provides guidance based on the objective findings detailed herein. This study, at the time of publication, represents the largest collection of patients that have undergone the VCC (N = 51) and their outcomes at 1 year. Those who remained healed without recurrence, amputation, or mortality at 1-year follow-up were 31.4%. Post-VCC total limb salvage rate is 68.6% at one year, mean follow-up 663.9 ± 464.7 days. One-year all-cause mortality post-VCC was 9.8%. Post-VCC function at 1-year follow-up reflects 79.3% of patients having the same or better function that their perioperative state.
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Affiliation(s)
- Helene Cook
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Christopher Kennedy
- MedStar Georgetown University Hospital Diabetic Limb Salvage Fellow, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Kevin Delijani
- Medical Student, Georgetown University Medical School, Washington DC
| | - Daniel Popovsky
- Medical Student, Georgetown University Medical School, Washington DC
| | - Tammer Elmarsafi
- Attending Physician, Potomac Podiatry Group PLLC, Woodbridge, VA
| | - Caitlin Zarick
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Christopher Attinger
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - John Steinberg
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC.
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21
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Gennai S, Leone N, Covic T, Migliari M, Lonardi R, Silingardi R. Health-related quality of life outcomes and Hospitalization length of stay after micro-fragmented autologous adipose tissue injection in minor amputations for diabetic foot ulceration (MiFrAADiF trial): results from a randomized controlled single-center clinical trial. INT ANGIOL 2021; 40:512-519. [PMID: 34515448 DOI: 10.23736/s0392-9590.21.04570-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The diabetic foot ulcer (DFU) is a high prevalence complication that significantly impairs the health-related quality of life (HRQoL) and is characterized by prolonged hospital length of stay (LOS). The impact of the micro-fragmented autologous adipose tissue injection at the minor amputation wound in the case of DFU (MiFrAADiF) on HRQoL and LOS compared to the standard care has not been determined yet. METHODS This was a two-arm, 6-month, individually randomized controlled single-center clinical trial. A 1:1 randomization to local injection of autologous micro-fragmented adipose tissue (treatment group; n=57) or standard clinical care (control group; n=57) was performed. The primary objective was the HRQoL. The secondary endpoint was the LOS. HRQoL was assessed with the Medical Outcomes Study 36-item Short-Form Health Survey which provides 2 scores focused on physical (PCS) and mental functioning (MCS). The trial was registered in ClinicalTrials.gov (NCT03276312). RESULTS The type of treatment (p=0.009) and the time elapsed since surgery (p= 0.0000) demonstrated a significant improvement on PCS. The MCS improvements resulted in a non-significant association with treatment (p= 0.21). The time elapsed since surgery showed a significant influence on the MCS (p= 0.0000). The mean LOS was 16.2 days and 24.4 days for the treatment and the control group respectively (p= 0.025). CONCLUSIONS The MiFrAADiF trial demonstrated a significant improvement in terms of physical HRQoL and a significant reduction of the hospital length of stay after injection of micro-fragmented autologous adipose tissue in diabetic patients' minor amputations wound.
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Affiliation(s)
- Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy -
| | - Tea Covic
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Mattia Migliari
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Lonardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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22
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Kotha VS, Fan KL, Schwitzer JA, Youn R, Black CK, Attinger CE, Evans KK. Amputation versus Free Flap: Long-Term Outcomes of Microsurgical Limb Salvage and Risk Factors for Amputation in the Diabetic Population. Plast Reconstr Surg 2021; 147:742-50. [PMID: 33587553 DOI: 10.1097/PRS.0000000000007644] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reconstructive microsurgery is an effective limb-saving option for nonhealing lower extremity wounds in diabetic patients. However, the ability to predict the future need for amputation is unclear. This article seeks to identify risk factors for amputation following microsurgical free tissue transfer in the diabetic lower extremity. METHODS Diabetic patients undergoing lower extremity free flap surgery between August of 2011 and January of 2018 performed by a single surgeon were identified retrospectively. Patient comorbidities, reconstructive conditions and flap traits, microsurgical outcomes, and long-term outcomes were examined. Variables conferring risk for future amputation were examined by means of regression analysis. RESULTS Sixty-four patients met the criteria. The overall immediate flap success rate was 94 percent (60 of 64). Long term, 50 patients (78.1 percent) underwent successful salvage, and 14 patients (21.9 percent) required major amputation. Acute flap loss resulted in four amputations, and delayed complications (hematoma, infection, recurrent nonhealing) resulted in 10 amputations. The average time to amputation was 5.6 months. Risk factors for amputation were end-stage renal disease (OR, 30.7; p = 0.0087), hindfoot wounds (OR, 4.6; p = 0.020), elevated hemoglobin A1C level greater than 8.4 percent (OR, 1.4; p = 0.05), and positive wound cultures (OR, 6.1; p = 0.003). CONCLUSIONS Multiple comorbidities and poor glucose control were identified as risk factors for amputation after free flap limb salvage. However, successful limb preservation is possible. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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23
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Basiri R, Haverstock BD, Petrasek PF, Manji K. Reduction in Diabetes-Related Major Amputation Rates After Implementation of a Multidisciplinary Model: An Evaluation in Alberta, Canada. J Am Podiatr Med Assoc 2021; 111:436244. [PMID: 31674800 DOI: 10.7547/19-137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Diabetes-related lower limb amputations (LLAs) are a major complication that can be reduced by employing multidisciplinary center frameworks such as the Toe and Flow model (TFM). In this study, we investigate the LLAs reduction efficacy of the TFM compared to the standard of care (SOC) in the Canadian health-care system. METHODS We retrospectively reviewed the anonymized diabetes-related LLA reports (2007-2017) in Calgary and Edmonton metropolitan health zones in Alberta, Canada. Both zones have the same provincial health-care coverage and similar demographics; however, Calgary operates based on the TFM while Edmonton with the provincial SOC. LLAs were divided into minor and major amputation cohorts and evaluated using the chi-square test, linear regression. A lower major LLAs rate was denoted as a sign for higher efficacy of the system. RESULTS Although LLAs numbers remained relatively comparable (Calgary: 2238 and Edmonton: 2410), the Calgary zone had both significantly lower major (45%) and higher minor (42%) amputation incidence rates compared to the Edmonton zone. The increasing trend in minor LLAs and decreasing major LLAs in the Calgary zone were negatively and significantly correlated (r = -0.730, p = 0.011), with no significant correlation in the Edmonton zone. CONCLUSIONS Calgary's decreasing diabetes-related major LLAs and negative correlation in the minor-major LLAs rates compared to its sister zone Edmonton, provides support for the positive impact of the TFM. This investigation includes support for a modernization of the diabetes-related limb preservation practice in Canada by implementing TFMs across the country to combat major LLAs.
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24
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Green CJ, Bibbo C, McArdle A, Knight C. A Functional Chopart's Amputation With Tendon Transfers. J Foot Ankle Surg 2021; 60:213-217. [PMID: 32981826 DOI: 10.1053/j.jfas.2020.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/15/2019] [Accepted: 08/24/2020] [Indexed: 02/03/2023]
Abstract
Generally, forefoot osteomyelitis is treated with a reliable level of amputation such as at the transmetatarsal level. However, when osteomyelitis extends proximal to the midfoot and presents with significant peripheral arterial disease, it is generally thought that the next best functional level of amputation is a transtibial amputation. This is mostly in part due to the high failure rate of Chopart's amputations which can be attributed to poor biomechanical and tendon balancing. We present a new technique of tendon balancing with a Chopart's amputation that results in optimized ambulatory function, durable soft tissue envelope of amputation, and successful limb salvage.
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Affiliation(s)
- Christopher J Green
- Medical Director of the INTEGRIS Southwest Medical Center Limb Salvage and Peripheral Arterial Disease Center, Oklahoma City, OK
| | - Christopher Bibbo
- Chief, Foot & Ankle Service, Plastic Reconstructive and Microsurgery, Orthopaedic Trauma, Musculoskeletal Infections, Limb Salvage, International Limb Lengthening Center at the Rubin Institute for Advanced Orthopaedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Austin McArdle
- Resident Surgeon, Surgical Hospital of Oklahoma and Cleveland Clinic Foundation Residency, Oklahoma City, OK
| | - Chad Knight
- Resident Surgeon, Surgical Hospital of Oklahoma and Cleveland Clinic Foundation Residency, Oklahoma City, OK.
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25
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Meshkin DH, Zolper EG, Chang K, Bryant M, Bekeny JC, Evans KK, Attinger CE, Fan KL. Long-term Mortality After Nontraumatic Major Lower Extremity Amputation: A Systematic Review and Meta-analysis. J Foot Ankle Surg 2021; 60:567-576. [PMID: 33509714 DOI: 10.1053/j.jfas.2020.06.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/17/2020] [Accepted: 06/23/2020] [Indexed: 02/03/2023]
Abstract
Chronic wounds that lead to major lower extremity amputation have immense consequences on quality of life, and ultimately, mortality. However, mortality rates after lower extremity amputation for a chronic wound are broad within the literature and have escaped precise definition. This systematic review aims to quantify long-term mortality rates after major lower extremity amputation in the chronic wound population available in the existing literature. Ovid MEDLINE was searched for publications which provided mortality data after major, nontraumatic, primary lower extremity amputations. Lower extremity amputations were defined as below and above the knee amputation. Data from included studies was analyzed to obtain pooled 1-, 2-, 3-, 5- and 10-year mortality rates. Sixty-one studies satisfied inclusion criteria representing 36,037 patients who underwent nontraumatic major lower extremity amputation. Pooled mortality rates were 33.7%, 51.5%, 53%, 64.4%, and 80% at 1-, 2-, 3-, 5- and 10-year follow-up, respectively. Within the 8184 diabetic patients (types 1 and 2), 1- and 5-year mortality was 27.3% and 63.2%. Sources of mortality data were varied and included electronic medical records, national health and insurance registries, and government databases. Mortality after nontraumatic major lower extremity amputation is high, both in patients with diabetes as well as those without. Methods used to measure and report mortality are inconsistent, lack reliability, and may underestimate true mortality rates. These findings illustrate the need for a paradigm shift in wound management and improved outcomes reporting. A focus on amputation prevention and care within a multidisciplinary team is critical for recalcitrant ulcers.
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Affiliation(s)
- Dean H Meshkin
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Elizabeth G Zolper
- Medical Student, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Kevin Chang
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Meigan Bryant
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Jenna C Bekeny
- Medical Student, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Professor of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington
| | - Christopher E Attinger
- Professor of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington
| | - Kenneth L Fan
- Assistant Professor Plastic Surgery, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC.
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26
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Balduzzi G, De Giglio R, Masserini B, Formenti I, Lodigiani S, Mondello T, Mumoli N, Pintaudi B, Di Vieste G. Effectiveness, Safety, and Acceptance of an Interim Orthosis in Patients with Diabetes in the Immediate Postoperative Chopart Surgery. INT J LOW EXTR WOUND 2021:15347346211023041. [PMID: 34096795 DOI: 10.1177/15347346211023041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chopart amputation is the consequence of severe diabetes-related foot complications. A new interim orthosis allowing the patient a greater degree of mobility after Chopart surgery than currently used systems is now available. The aim of this study was to evaluate the effectiveness of the new orthosis compared with traditional treatment. Safety and level of patient acceptance of the device were also investigated. We performed a retrospective case-control observational study involving people with diabetes who underwent Chopart amputation between January 2016 and January 2018. The sample of subjects treated with the innovative orthosis was compared with consecutive patients, who were treated with traditional management. The main study outcomes include major amputation occurrence, ulcer recurrence, healing time, and patient acceptance of the orthosis. Patient satisfaction was evaluated using the Italian validated version of the Orthotic Prosthetic User's Survey (OPUS) questionnaire. Overall, 27 subjects were enrolled using the new device (mean age 68.7 ± 8.4 years, 70.4% males, mean diabetes duration 22.7 ± 15 years). Clinical baseline characteristics were comparable between the cases and the controls. There was no difference between the groups in the healed wound rate (81.5% vs 80.0% for cases and the control group, respectively, P = .53). The ulcer recurrence rate was higher in the control group compared with subjects using the new orthosis (62.5% vs 24.0%, respectively, P = .04). The use of the innovative orthosis was associated with an 81% lower probability to have ulcer recurrence (odds ratio 0.19, 95% confidence interval 0.04-1.04). No between groups difference was detected for a major amputation rate. The wound healing time was faster for cases compared with controls (160.4 ± 114.1 vs 256.5 ± 112.9 days, P = .05). No adverse events related to the use of the new orthosis were recorded. Patient acceptance of the new orthosis was high. This orthosis can be recommended as an efficient, safe, and well-accepted device after Chopart amputation.
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Affiliation(s)
| | | | | | - Ilaria Formenti
- Abbiategrasso Hospital, 9338ASST Ovest Milanese, Milan, Italy
| | - Sara Lodigiani
- Abbiategrasso Hospital, 9338ASST Ovest Milanese, Milan, Italy
| | - Teresa Mondello
- Abbiategrasso Hospital, 9338ASST Ovest Milanese, Milan, Italy
| | - Nicola Mumoli
- Magenta Hospital, 472668ASST Ovest Milanese, Milan, Italy
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Fan KL, Singh T, Bekeny JC, Zolper EG, Dekker PK, Attinger CE, Evans KK, DeLia D. Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets. Plast Reconstr Surg Glob Open 2021; 9:e3183. [PMID: 33680630 DOI: 10.1097/GOX.0000000000003183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/22/2020] [Indexed: 11/25/2022]
Abstract
Wounds in the comorbid population require limb salvage to prevent amputation. Extensive health economics literature demonstrates that hospital activities are influenced by level of market concentration. The impact of competition and market concentration on limb salvage remains to be determined. Methods Admissions for chronic lower extremity wounds in nonrural hospitals were identified in the 2010-2011 National Inpatient Survey using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, salvage without flap techniques (eg, skin grafts), or salvage with flap techniques. The all-service Herfindahl-Hirschman Index (HHI), which is a commonly used tool for market and antitrust analyses, was used to measure hospital competition. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the relationship between the HHI and hospital adoption of limb salvage controlling for patient, hospital, and market factors. Results The study cohort represents 124,836 admissions nationally: 89,880 amputations, 26,715 salvage without flap techniques, and 8241 salvage flap techniques. Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps (P < 0.01). Other factors were less predictive. Conclusion Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among patients with chronic wounds. Improving access to reconstructive limb services must consider the competitive structure of hospital markets.
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28
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Bekeny JC, Zolper EG, Steinberg JS, Attinger CE, Fan KL, Evans KK. Free Tissue Transfer for Patients with Chronic Lower Extremity Wounds. Clin Plast Surg 2021; 48:321-9. [PMID: 33674053 DOI: 10.1016/j.cps.2021.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Chronic lower extremity wounds are defined as wounds that fail to heal within 3 months of defect onset. Free tissue transfer offers an opportunity for limb salvage and length preservation. Preoperative optimization includes a medical and nutritional consult, complete work-up by vascular surgery, and an analysis of bony stability and gait biomechanics by podiatric surgery. In the authors' practice, the thigh has proved the workhorse donor site and offers fasciocutaneous and muscle-based flaps depending on defect characteristics. Postoperative care requires early monitoring for flap compromise and continued long-term follow-up for wound recurrence.
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29
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Rümenapf G, Morbach S, Rother U, Uhl C, Görtz H, Böckler D, Behrendt CA, Hochlenert D, Engels G, Hohneck A, Sigl M. [Diabetic foot syndrome-Part 2 : Revascularization, treatment alternatives, care structures, recurrency prophylaxis]. Chirurg 2021; 92:173-186. [PMID: 33237367 PMCID: PMC7875854 DOI: 10.1007/s00104-020-01313-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Diabetic foot syndrome (DFS) is the most frequent reason for major amputations in Germany. The majority of foot lesions are triggered by repetitive pressure in diabetic polyneuropathy. Peripheral arterial occlusive disease (PAOD) impairs wound healing and is the main risk factor for amputations. The treatment of wounds and infections as well as timely revascularization are decisive. The use of endovascular and vascular surgical methods depends on the distribution pattern and length of the occlusion processes. Both procedures are complementary. Bypass surgery is of great importance for neuroischemic DFS. Multidisciplinary centers that provide revascularization in DFS can achieve an improvement of arterial blood flow in 90% of the cases and reduce the amputation rate by up to 80%. Due to the high recurrence rate of diabetic foot lesions, measures for secondary prophylaxis are of exceptional importance (podological and orthopedic technical care, foot surgery).
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Affiliation(s)
- G Rümenapf
- Oberrheinisches Gefäßzentrum Speyer, Diakonissen-Stiftungs-Krankenhaus Speyer, Paul-Egell-Straße 33, 67346, Speyer, Deutschland.
| | - S Morbach
- Abteilung Diabetologie und Angiologie, Fachbereich , Innere Medizin, Marienkrankenhaus gGmbH Soest, Soest, Deutschland
| | - U Rother
- Gefäßchirurgische Abteilung, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - C Uhl
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - H Görtz
- Klinik für Gefäßchirurgie, Bonifatius Hospital Lingen, Lingen, Deutschland
| | - D Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C A Behrendt
- Klinik und Poliklinik für Gefäßmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - D Hochlenert
- Centrum für Diabetologie, Endoskopie und Wundheilung Köln, Köln, Deutschland
| | - G Engels
- Chirurgische Praxis am Bayenthalgürtel, Köln, Deutschland
| | - A Hohneck
- Abteilung für Angiologie, 1. Medizinische Klinik, Universitätsklinik Mannheim, Mannheim, Deutschland
| | - M Sigl
- Abteilung für Angiologie, 1. Medizinische Klinik, Universitätsklinik Mannheim, Mannheim, Deutschland
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30
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Wang L, Wang C, Chen H, Chen Y, Li J, Xiao L, Zhu D, Yang C. The Combined Use of a Non-Invasive Skin-Stretching Device and the Negative-Pressure Wound Therapy Technique in the Treatment of Postoperative Diabetic Foot. Diabetes Metab Syndr Obes 2021; 14:3523-3532. [PMID: 34385827 PMCID: PMC8352599 DOI: 10.2147/dmso.s322757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/13/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The present study explored the effectiveness of using a non-invasive skin-stretching device (NSSD) combined with negative-pressure wound therapy (NPWT) for the postoperative wound repair of diabetic foot (DF) gangrene. METHODS The treatment group in this study involved 42 patients with Wagner grade 3-4 DF and undergone concomitant toe amputation or debridement, who were given NPWT combined with the use of a NSSD. The control group comprised 42 patients with similar trauma areas (±20%) that were matched at a ratio of 1:1. Following surgery, these patients received NPWT combined with the use of conventional dressings. A comparison was made of the postoperative wound healing rates and wound healing times of the two groups, with Kaplan-Meier survival analysis being used to compare the healing rate over time. RESULTS The three-month wound healing rate was higher in the treatment group than in the control group (38 of 42 [90.5%] vs 25 of 42 [59.5%], p = 0.002), and the wound healing time was shorter in the treatment group (44 days [95% CI 40.0-48.0]) than that in the control group (76 days [95% CI 63.0-89.0], p = 0.000). Taking the end of the final NPWT as the starting point, the comparison of wound healing time revealed that this period was shorter in the treatment group than that in the control group and the difference was statistically significant (11 days [95% CI 9.0-13.0] vs 42 days [95% CI 23.0-ND], p = 0.000). CONCLUSION The use of the NPWT technique combined with a NSSD can shorten the wound healing time and improve the wound healing rate of DF gangrene patients during the postoperative wound repair period.
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Affiliation(s)
- Liangchen Wang
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Chenrui Wang
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Hongmei Chen
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Ying Chen
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Juan Li
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Li Xiao
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Di Zhu
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Caizhe Yang
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
- Correspondence: Caizhe Yang Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of ChinaTel/Fax +86 1066928242 Email
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31
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Albright RH, Joseph RM, Wukich DK, Armstrong DG, Fleischer AE. Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective? Clin Orthop Relat Res 2020; 478:2869-2888. [PMID: 32694315 PMCID: PMC7899431 DOI: 10.1097/corr.0000000000001416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/26/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. QUESTIONS/PURPOSES To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. METHODS A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. RESULTS The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. CONCLUSIONS Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. LEVEL OF EVIDENCE Level II, economic and decision analysis.
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Affiliation(s)
- Rachel H Albright
- R. H. Albright, The Dartmouth Institute, Geisel School of Medicine, Hanover, NH, USA
| | - Robert M Joseph
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Dane K Wukich
- D. K. Wukich, Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - David G Armstrong
- D. G. Armstrong, Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Adam E Fleischer
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- A. E. Fleischer, Weil Foot and Ankle Institute, Mount Prospect, IL, USA
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Liette MD, Ellabban MA, Rodriguez P, Bibbo C, Masadeh S. Medial Plantar Artery Flap for Wound Coverage of the Weight-Bearing Surface of the Heel. Clin Podiatr Med Surg 2020; 37:751-764. [PMID: 32919602 DOI: 10.1016/j.cpm.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Covering soft tissue defects of the heel is particularly challenging because of the highly specialized functional units unique to the plantar fat pad and the shear and compressive forces experienced in this area. The medial plantar artery fasciocutaneous flap provides the unique ability to restore both sensation and the functional units to the plantar heel by taking tissue similar to that which was lost and relocating it from a non-weight-bearing portion of the foot, while maintaining minimal host morbidity. This provides a lasting solution and may prevent future ulcerations from occurring.
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Affiliation(s)
- Michael D Liette
- University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Mohamed A Ellabban
- Suez Canal University Hospitals and Medical School, Ismailia 41522, Egypt
| | - Pedro Rodriguez
- Plastic and Reconstructive Surgery, OSF Saint Anthony Medical Center, 698 Featherstone Road, Rockford, IL 61107, USA
| | - Christopher Bibbo
- Foot & Ankle, Reconstructive Plastic & Microsurgery & Limb Salvage, Musculoskeletal Infection & Orthopaedic Trauma, Rubin Institute for Advanced Orthopaedics, International Center for Limb Lengthening, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215-5216, USA
| | - Suhail Masadeh
- University of Cincinnati Medical Center, Cincinnati Veteran Affairs Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA.
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Brodell JD, Ayers BC, Baumhauer JF, DiGiovanni BF, Flemister AS, Ketz JP, Oh I. Chopart Amputation: Questioning the Clinical Efficacy of a Long-standing Surgical Option for Diabetic Foot Infection. J Am Acad Orthop Surg 2020; 28:684-691. [PMID: 32769724 DOI: 10.5435/jaaos-d-19-00757] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers. METHODS We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded. RESULTS Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average. DISCUSSION In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation. LEVEL OF EVIDENCE IV, Case Series.
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Affiliation(s)
- James D Brodell
- From the Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
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Kwak DG, Hur JY, Moon JS, Chang MC. Short-Term Walking Outcomes in Diabetic and Non-Diabetic Unilateral Transtibial Amputees. Diabetes Metab J 2020; 44:614-618. [PMID: 31701697 PMCID: PMC7453990 DOI: 10.4093/dmj.2019.0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 06/24/2019] [Indexed: 11/08/2022] Open
Abstract
This study compared short-term walking outcomes in diabetic amputees after prosthesis fitting compared to that in non-diabetic amputees. We retrospectively investigated walking outcomes at 3 months after starting gait training with a prosthesis. Forty-four unilateral transtibial amputees with (n=18) and without diabetes (n=26) were included. At 3 months after gait training with a prosthesis, only 2/18 (11.1%) and 3/18 (16.7%) diabetic amputees were capable of independent outdoor and indoor walking without cane, respectively. However, 21/26 (80.8%) and 24/26 (92.3%) non-diabetic amputees were capable of independent outdoor and indoor walking without cane, respectively. With assistance of cane, most of non-diabetic amputees (n=24, 92.3%) were capable of walking in both outdoor and indoor but only seven (38.9%) and nine (50.0%) diabetic amputees were capable, respectively. Thus, short-term walking outcome were poor in transtibial amputee with diabetes compare to those without diabetes, and these results suggest intensive rehabilitation would be needed to them.
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Affiliation(s)
- Dong Gyu Kwak
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
| | | | - Jun Sung Moon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea.
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea.
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Fan KL, Delia D, Black CK, Zolper E, Singh T, Wirth P, Luvisa K, Song DH, Attinger CE, Evans KK. Who, What, Where: Demographics, Severity of Presentation, and Location of Treatment Drive Delivery of Diabetic Limb Reconstructive Services within the National Inpatient Sample. Plast Reconstr Surg 2020; 145:1516-27. [DOI: 10.1097/prs.0000000000006843] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Black C, Fan KL, Defazio MV, Luvisa K, Reynolds K, Kotha VS, Attinger CE, Evans KK. Limb Salvage Rates and Functional Outcomes Using a Longitudinal Slit Arteriotomy End-to-Side Anastomosis for Limb-Threatening Defects in a High-Risk Patient Population. Plast Reconstr Surg 2020; 145:1302-1312. [PMID: 32332556 DOI: 10.1097/prs.0000000000006791] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Limb salvage techniques using free tissue transfer in patients with chronic wounds caused by longstanding osteomyelitis, diabetes, and peripheral vascular disease are technically challenging. The longitudinal slit arteriotomy end-to-side anastomosis is the authors' preferred technique because it is the least invasive arteriotomy and is especially important for diseased recipient arteries. The authors reviewed highly comorbid patients who underwent free tissue transfer with this technique to understand the success rates, overall outcomes, and long-term limb salvage rates. METHODS A retrospective review was performed to analyze outcomes of free tissue transfer using longitudinal slit arteriotomy end-to-side anastomosis between 2012 and 2018 performed by the senior surgeon (K.K.E.). RESULTS One hundred fifteen free flaps were identified. Patients were, on average, 55.9 years old, with a body mass index of 29.2 kg/m. Comorbidities included osteomyelitis (83.5 percent), hypertension (60.9 percent), tobacco use (46.1 percent), diabetes (44.3 percent), peripheral vascular disease (44.3 percent), hypercoagulability (35.7 percent), and arterial calcifications (17.4 percent). Overall flap success was 93.0 percent; 27.8 percent required reoperation perioperatively because of complications. On univariate analysis, diabetes mellitus, hypertension, and hypercoagulability were significantly associated with eventual amputation (p < 0.05). Multivariate analysis showed that intraoperative thrombosis and take back was independently associated with flap failure. There was an overall limb salvage rate of 83.5 percent, and of those salvaged, 92.7 percent were ambulating without a prosthesis at a mean follow-up of 1.53 years. CONCLUSIONS This is the largest series of longitudinal slit arteriotomy end-to-side anastomosis for patients undergoing free tissue transfer for limb-threatening defects in the compromised host. Overall flap success, limb salvage rates, and functional outcomes are high using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Cara Black
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Kenneth L Fan
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Michael V Defazio
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Kyle Luvisa
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Kyle Reynolds
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Vikas S Kotha
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Christopher E Attinger
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Karen K Evans
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
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Abstract
Diabetic foot ulcers remain a challenge to practitioners and costly to health care systems. They range from simple to complex and many treatment options are available. By following standard wound care protocols to ensure adequate blood supply, infection control, debridement, wound management, and offloading many diabetic foot ulcers heal in a timely fashion. For those that do not, an underlying foot and ankle musculoskeletal abnormality must be suspected and treated concomitantly with soft tissue treatment. This article presents a systematic orthoplastics approach for surgical treatment of diabetic foot ulcers using the soft tissue reconstructive ladder and the musculoskeletal reconstructive matrix.
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Affiliation(s)
- Collin E Pehde
- College of Podiatric Medicine and Surgery, Des Moines University, 3200 Grand Avenue, Des Moines, IA 50312, USA.
| | - John Bennett
- College of Podiatric Medicine and Surgery, Des Moines University, 3200 Grand Avenue, Des Moines, IA 50312, USA
| | - Megan Kingston
- College of Podiatric Medicine and Surgery, Des Moines University, 3200 Grand Avenue, Des Moines, IA 50312, USA
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Wilkinson HN, Hardman MJ. Wound senescence: A functional link between diabetes and ageing? Exp Dermatol 2020; 30:68-73. [PMID: 32009254 DOI: 10.1111/exd.14082] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/13/2020] [Accepted: 01/21/2020] [Indexed: 12/11/2022]
Abstract
Arguably, the two most important causes of pathological healing in the skin are diabetes and ageing. While these factors have historically been considered independent modifiers of the healing process, recent studies suggest that they may be mechanistically linked. The primary contributor to diabetic pathology is hyperglycaemia, which accelerates the production of advanced glycation end products, a characteristic of ageing tissue. Indeed, advanced age also leads to mild hyperglycaemia. Here, we discuss emerging literature that reveals a hitherto unappreciated link between cellular senescence, diabetes and wound repair. Senescent cells cause widespread destruction of normal tissue architecture in ageing and have been shown to be increased in chronic wounds. However, the role of senescence remains controversial, with several studies reporting beneficial effects for transiently induced senescence in wound healing. We recently highlighted a direct role for senescence in diabetic healing pathology, mediated by the senescence receptor, CXCR2. These findings suggest that targeting local tissue senescence may provide a therapeutic strategy applicable to a broad range of chronic wound types.
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Affiliation(s)
- Holly N Wilkinson
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, The University of Hull, Hull, UK
| | - Matthew J Hardman
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, The University of Hull, Hull, UK
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Ha J, Hester T, Foley R, Reichert IL, Vas PR, Ahluwalia R, Kavarthapu V. Charcot foot reconstruction outcomes: A systematic review. J Clin Orthop Trauma 2020; 11:357-368. [PMID: 32405193 PMCID: PMC7211810 DOI: 10.1016/j.jcot.2020.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications. METHODS We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques. RESULTS A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation. CONCLUSIONS Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.
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Affiliation(s)
- Joon Ha
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Thomas Hester
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Robert Foley
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Ines L.H. Reichert
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Prashanth R.J. Vas
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom,King’s Diabetic Foot Clinic, King’s College College Hospital, London
| | - Raju Ahluwalia
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom,Corresponding author.
| | - Venu Kavarthapu
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
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Abstract
BACKGROUND Ankle fractures in patients with complicated diabetes have significantly increased the rates of complications and poorer functional outcomes when treated nonoperatively, and there have been only modest reductions when treated operatively. We hypothesized that the minimally invasive, robust construct that tibiotalocalcaneal fixation with an intramedullary nail offers would result in high rates of limb salvage, acceptable rates of complications, and less loss of function, in this difficult patient population. METHODS This was an institutional review board-approved retrospective study of 27 patients with complicated diabetes who underwent tibiotalocalcaneal nailing of their ankle fracture as a primary treatment without formal joint preparation. Patients with complicated diabetes were defined as having neuropathy, nephropathy, and/or peripheral vascular disease. The mean clinical follow-up was 888 days. Patients were screened for associated risk factors. Data were collected on surgical complications. The outcomes measured included length of hospital stay, loss of ambulatory level, amputation, and time to death. The mean age was 66 years with an average body mass index of 38 and hemoglobin A1c of 7.4. Six fractures were open. RESULTS The limb salvage rate was 96%. The average hospital stay was 6 days, and the mean time to weightbearing was 6.7 weeks. The fracture union rate was 88%. The surgical complication rate was 18.5%, with no instances of malunions, symptomatic nonunions, or Charcot arthropathy. Eight patients died by final follow-up (mean, 1048 days). An ambulatory level was maintained in 81% of the patients. CONCLUSION With high limb salvage rates, relatively early weightbearing, maintained ambulatory level, and acceptable complication rates, we believe our technique can be considered an appropriate approach to increase the overall survivability of threatened limbs and lives in this patient population. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | | | - David Goss
- Orthopedic Foot and Ankle Center, Westerville, OH, USA
| | - Benjamin C Taylor
- OhioHealth Orthopedic Trauma and Reconstructive Surgeons, Grant Medical Center, Columbus, OH, USA
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Cates NK, Wang K, Stowers JM, Attinger CE, Kim PJ, Steinberg JS. The Vertical Contour Calcanectomy, an Alternative Approach to Surgical Heel Ulcers: A Case Series. J Foot Ankle Surg 2019; 58:1067-1071. [PMID: 31679660 DOI: 10.1053/j.jfas.2019.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 03/31/2019] [Accepted: 04/05/2019] [Indexed: 02/03/2023]
Abstract
Heel ulcers have a significant impact on lower-extremity morbidity and confer high risk of major amputations. Treating these ulcers is difficult because of poor tissue coverage and the bony os calcis, often leading to proximal amputation. This case series shows the vertical contour calcanectomy (VCC) as a surgical alternative in functional limb salvage. Sixteen feet (14 patients) with recalcitrant heel wounds who underwent VCC were identified. The minimum follow-up time for inclusion was 1 year. Body mass index, diabetes, renal disease, peripheral vascular disease, lymphedema/venous insufficiency, smoking status, Charcot, amputation, vascular intervention, wound recurrence, reoperation rate, and ambulatory status were evaluated. The average follow-up time was 27.1 months (range 13.5 to 51.1). At 1 year of follow-up, 56% of heel wounds (9 of 16) treated with the VCC remained closed. An average of 1.44 subsequent surgeries were required per patient. Baseline or improved ambulatory status was achieved in 69% of patients (9 of 14) at 1-year follow up and 100% of patients (8 of 8) at 2-year follow up. The overall rate of major amputation was 19%. The long-term ambulatory status of patients treated with the VCC shows promise. The VCC should be considered as an alternative, reliable, surgical limb salvage tool for heel ulcerations.
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Affiliation(s)
- Nicole K Cates
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC, USA
| | - Kaihua Wang
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC, USA
| | - Jered M Stowers
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC, USA
| | - Christopher E Attinger
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Paul J Kim
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - John S Steinberg
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA.
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Abstract
BACKGROUND There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation. METHODS In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population. RESULTS The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease. CONCLUSION Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.
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Affiliation(s)
- Cara K Black
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Laurel D Ormiston
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Kenneth L Fan
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Vikas S Kotha
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Christopher Attinger
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Karen Kim Evans
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
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Park JU, Oh B, Lee JP, Choi MH, Lee MJ, Kim BS. Influence of Microbiota on Diabetic Foot Wound in Comparison with Adjacent Normal Skin Based on the Clinical Features. Biomed Res Int 2019; 2019:7459236. [PMID: 31531366 DOI: 10.1155/2019/7459236] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/22/2019] [Indexed: 01/13/2023]
Abstract
Diabetic foot ulcer (DFU) is a complication experienced by diabetic patients and does not heal well in an altered wound environment. Although diverse microbes in DFU were detected, little is known about their influences on diabetic foot wound (DFW) and the association with the skin microbiota in normal tissue from the same patients according to clinical features. We aimed to analyze the microbiota in normal skin and DFW tissue from the same subject and predict their roles based on clinical features. We analyzed the microbiota in normal skin and DFW tissue from the same subject and compared the associated members of microbiota with clinical parameters. The diversity of skin microbiota was higher than that of DFW tissues, along with compositional differences. In addition, different microbes were associated with clinical features. The proportions of Bacteroidetes, Prevotella, Peptoniphilus, Porphyromonas, and Dialister were higher in the severe groups than of the mild groups, whereas that of Firmicutes was lower in the severe groups. According to wound severity, the microbiota could be related to inflammation, damaging host cell membrane, and pathogenicity through lipopolysaccharide biosynthesis, cellular antigens, and protein digestion metabolism. The predicted DFW microbiota functions according to systemic diabetic status defined by ESRD and HbA1c, differed from those presented by wound severity. Results indicate that the microbiota in normal skin is related to the colonizing microbes in DFW tissue according to clinical features and the different microbes can play important roles in DFW prognosis. This information can be applied to prevent and manage DFW by modulating the microbiota.
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Abstract
Tissue defects that result from diabetic foot infections are often complex and necessitate reconstructive soft-tissue surgery to achieve closure. Intrinsic muscle flaps of the foot require attention to major vascular pedicles and are useful for closing smaller ulcerations. Microvascular free flaps are beneficial for large defects and provide long-term survivability. Perioperative planning is an important aspect of caring for diabetic patients requiring reconstructive surgery. These techniques are valuable tools for use in efforts to preserve a functional limb in this patient population.
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Affiliation(s)
- Cara K Black
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC 20007, USA
| | - Vikas S Kotha
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC 20007, USA
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC 20007, USA
| | - Kevin Ragothaman
- Division of Podiatric Surgery, MedStar Georgetown University, 3800 Reservoir Road, Washington, DC 20007, USA
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC 20007, USA
| | - Karen Kim Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC 20007, USA.
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Kotha VS, Ragothaman K, Walters E, Attinger CE, Steinberg JS. Lower Extremity Amputations in At-Risk Patients: A Focus on Tissue Viability and Function in the Compromised Limb. Clin Podiatr Med Surg 2019; 36:483-98. [PMID: 31079612 DOI: 10.1016/j.cpm.2019.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Amputations distal to the ankle joint are commonly performed in efforts to preserve a limb. Thorough examination of lower extremity biomechanics, patient functional status, and patient goals must be used to help prevent reulceration and further amputation. Once infection is resolved in the acute setting, musculotendon balancing should be considered at the time of amputation closure to maintain functionality of the limb. Patients should be closely followed postoperatively and monitored for biomechanical deformity that needs to be addressed. Careful attention to detail and adherence to surgical principles can help keep patients active and prevent further amputation.
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Elmarsafi T, Pierre AJ, Wang K, Evans KK, Attinger CE, Kim PJ, Steinberg JS. The Vertical Contour Calcanectomy: An Alternative Surgical Technique to the Conventional Partial Calcanectomy. J Foot Ankle Surg 2019; 58:381-386. [PMID: 30612862 DOI: 10.1053/j.jfas.2018.08.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Indexed: 02/03/2023]
Abstract
Heel ulcers have a significant impact on lower extremity morbidity and confer a high risk for major amputations. Although there are many conservative treatment options, once calcaneal osteomyelitis occurs or a heel ulcer becomes chronic or recalcitrant, more invasive management is required. The partial calcanectomy is a surgical solution that can address both pathologies-the ulceration and the infected bone. The conventional partial calcanectomy, however, does not ensure complete soft tissue closure. Often, closure under tension is required for primary closure of the soft tissue deficit or the wound must be closed by secondary intention. This process occurs, in part, when the proportion of bone resected is insufficient in relation to the size of the wound. Closure under tension increases the possibility of dehiscence and subsequent postoperative surgical site complications that lead to the same risks for major amputation as the index heel ulcer. This article introduces and describes a novel modification to the conventional partial calcanectomy and addresses these aforementioned concerns. The vertical contour calcanectomy incorporates improvements to an already accepted limb salvage technique. The purpose of this article was to describe the indications, contraindications, intraoperative technique and postoperative management of the vertical contour calcanectomy for patients who present with heel ulcers in the limb salvage setting.
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Affiliation(s)
- Tammer Elmarsafi
- Senior Surgeon, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Andrew J Pierre
- Resident Physician, Division of Podiatric Surgery, MedStar Washington Hospital Center, Washington DC
| | - Kaihua Wang
- Resident Physician, Division of Podiatric Surgery, MedStar Washington Hospital Center, Washington DC
| | - Karen K Evans
- Senior Surgeon, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher E Attinger
- Senior Surgeon, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Paul J Kim
- Senior Surgeon, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - John S Steinberg
- Senior Surgeon, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC.
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47
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Abstract
Diabetes mellitus is a devastating disease that has reached epidemic proportions. The surgical patient with diabetes is at increased risk for developing complications when compared with patients without diabetes. A comprehensive preoperative work-up must be performed, including ancillary studies, with optimization of the patient's glucose levels during the perioperative period to decrease the chance of developing surgical complications. A multispecialty team approach for the care of patients with diabetes should be used to produce successful surgical outcomes.
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Affiliation(s)
- Keith D Cook
- Podiatry Department, University Hospital, 150 Bergen Street, Room G-142, Newark, NJ 07103, USA.
| | - John Borzok
- Podiatric Medicine and Surgery Residency Program, University Hospital, 150 Bergen Street, Room G-142, Newark, NJ 07103, USA
| | - Fadwa Sumrein
- Department of Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103, USA
| | - Douglas J Opler
- Department of Psychiatry, Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103, USA
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48
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Kim CH, Moon JS, Chung SM, Kong EJ, Park CH, Yoon WS, Kim TG, Kim W, Yoon JS, Won KC, Lee HW. The Changes of Trends in the Diagnosis and Treatment of Diabetic Foot Ulcer over a 10-Year Period: Single Center Study. Diabetes Metab J 2018; 42:308-319. [PMID: 29885115 PMCID: PMC6107356 DOI: 10.4093/dmj.2017.0076] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 03/13/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND This study aims to describe the trends in the severity and treatment modality of patients with diabetic foot ulcer (DFU) at a single tertiary referral center in Korea over the last 10 years and compare the outcomes before and after the introduction of a multidisciplinary diabetic foot team. METHODS In this retrospective observational study, electronic medical records of patients from years 2002 to 2015 at single tertiary referral center were reviewed. Based on the year of first admission, patients were assigned to a group either before or after the year 2012, the year the diabetes team launched. RESULTS Of the 338 patients with DFU, 229 were first admitted until the year 2011 (group A), while 109 were first admitted since the year 2012 (group B). Mean age was higher in group B, and ulcer size was larger than those of group A. Whereas duration of diabetes was longer in group B, glycemic control was improved (mean glycosylated hemoglobin, 9.48% vs. 8.50%). The proportion of minor lower extremity amputation (LEA) was increased, but length of hospital stay was decreased (73.7±79.6 days vs. 39.8±36.9 days). As critical ischemic limb increased, the proportion of major LEA was not decreased. CONCLUSION Improved glycemic control, multidisciplinary strategies with prompt surgical treatment resulted in reduced length of hospital stay, but these measures did not reduce major LEAs. The increase in critical ischemic limb may have played a role in the unexpected outcome, and may suggest the need for increased vascular intervention strategies in DFU treatment.
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Affiliation(s)
- Choong Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jun Sung Moon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Seung Min Chung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Eun Jung Kong
- Department of Nuclear Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Chul Hyun Park
- Department of Orthopedic Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Woo Sung Yoon
- Division of Vascular Surgery, Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Gon Kim
- Department of Plastic Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Woong Kim
- Division of Cardiology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Ji Sung Yoon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyu Chang Won
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Hyoung Woo Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea.
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49
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Kim YK, Lee HS, Ryu JJ, In Lee H, Seo SG. Sarcopenia increases the risk for mortality in patients who undergo amputation for diabetic foot. J Foot Ankle Res 2018; 11:32. [PMID: 29946364 PMCID: PMC6006937 DOI: 10.1186/s13047-018-0274-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/05/2018] [Indexed: 12/25/2022] Open
Abstract
Background Although there have been reports that diabetes affects the prevalence of sarcopenia, no studies have examined the relationship between sarcopenia and mortality in patients undergoing leg amputation. The purpose of this study is to determine whether sarcopenia affects the mortality rate of patients undergoing diabetic foot amputation. Methods From among patients who underwent limb amputation for diabetes complications, this study included 167 patients who underwent abdominal CT within 1 year of amputation. We defined sarcopenia using sex-specific cut-off points for the L3 skeletal muscle index. The 5-year survival rate was analyzed. All patients were divided into two groups and compared according to the presence of sarcopenia. The mortality rate according to sarcopenia was assessed via the Kaplan-Meier method and log-rank test. Uni- and multivariate Cox regression analyses evaluated factors associated with survival rate. Results Among the total of 167 patients, the overall 5-year mortality rate was 52.7%. Of the 112 patients with sarcopenia, the 5-year mortality rate was 60.7%. Of the 55 patients without sarcopenia, the 5-year mortality rate was 36.4%. Kaplan-Meier analysis showed a high mortality of the sarcopenia group in the univariate (p = 0.016) and multivariate (p = 0.047) analysis. Conclusions Our study is the first to analyze the relationship between diabetic amputation and sarcopenia. Sarcopenia increases the risk of mortality in patients who undergo amputation for diabetic foot. Therefore, patients with diabetes should be careful to prevent sarcopenia with enough regular exercise as well as prevent diabetic foot disease.
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Affiliation(s)
- You Keun Kim
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Ho Seong Lee
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Jae Jung Ryu
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Hye In Lee
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Sang Gyo Seo
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea.,2Diabetes Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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50
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Wukich DK, Raspovic KM. Assessing Health-Related Quality of Life in Patients With Diabetic Foot Disease: Why Is It Important and How Can We Improve? The 2017 Roger E. Pecoraro Award Lecture. Diabetes Care 2018; 41:391-397. [PMID: 29463665 DOI: 10.2337/dci17-0029] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patient-reported outcomes (PROs) have become an important subject in the area of diabetes-related foot complications. Self-reported health-related quality of life (HRQOL) surveys can provide a generic measure of overall health (global) and can be disease specific (i.e., diabetes) or even region specific (i.e., lower-extremity function). Analysis of PRO measures utilizing validated instruments allows health care providers to determine whether medical and surgical treatments are providing patients with the highest level of outcome possible and are actually improving HRQOL. The 36-item Short Form (SF-36), EuroQol five-dimension questionnaire (EQ-5D-5L), and Foot and Ankle Ability Measure (FAAM) are examples of commonly used HRQOL surveys. Low HRQOL has been associated with higher rates of hospital admission and mortality in patients with diabetes. Previous studies have demonstrated that patients with diabetes-related foot disease have low self-reported physical quality of life but do not typically report low mental quality of life. The impact of mental quality of life may be underestimated in these patients using the SF-36. In this article, we will discuss several widely used outcome instruments used to measure patient HRQOL and the impact of diabetic foot disease on HRQOL. As health care providers, we must continue to adjust and modify our treatments to achieve the best patient outcomes and associated high quality of life. Assessing PROs will become increasingly important as health care systems transition from a volume-based reimbursement model to a value-based model.
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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