Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers

2019 ◽  
Vol 19 (3) ◽  
pp. 275-281 ◽  
Author(s):  
Marco Meloni ◽  
Valentina Izzo ◽  
Laura Giurato ◽  
Enrico Brocco ◽  
Roberto Gandini ◽  
...  
Keyword(s):  
Limb Salvage ◽  
Outcome Measures ◽  
Multidisciplinary Approach ◽  
Major Amputation ◽  
Foot Ulcers ◽  
Diabetic Patients ◽  
Study Group ◽  
Endovascular Technique ◽  
Consecutive Sample

The purpose of this study is to investigate the outcomes of diabetic individuals with ischemic heel ulcers. The study group was composed of a consecutive sample of persons with diabetic ischemic foot ulcers managed by a preset multidisciplinary limb salvage protocol, including revascularization through endovascular technique. The outcome measures were healing, major amputation (above the ankle), and death at 1-year of follow-up. The outcomes between patients with heel ulcers (HUs) and without (NHUs) were compared. A total of 254 patients were recruited. There were 50/254 (19.7%) HUs and 204/254 (79.3%) NHUs. Overall, 190/254 (74.8%) patients healed. The rate of healing for HUs and NHUs was 30/50 (60%) and 160/204 (78.4%); P = .03, respectively. Major amputation occurred in 24/254 (9.4%) patients. The rates of major amputation for HUs and NHUs were 10/50 (20%) and 14/204 (6.9%; P = .002), respectively; 40/254 (15.7%) patients died, unhealed. The rates of mortality for HUs and NHUs were 10/50 (20%) and 30/204 (14.7%; P = .07), respectively. In HUs patients, absence of infection [95% CI = 3.1 (1.6-5.5); P = .002] and superficial ulcers [95% CI = 4.4 (2.2-9.3); P = .0001] were independent predictors of healing, whereas revascularization failure [95% CI = 8.1 (1.5.0-19.4); P = .0001], involvement of the plantar arch [95% CI = 6.3 (2.0-15.4); P = .0001], and dialysis [95% CI = 2.2 (1.3-4.5); P = .006] were independent predictors of major amputation. A multidisciplinary approach achieves good rate of limb salvage in people with diabetic ischemic heel ulcers.

Healing of Diabetic Neuroischemic Foot Wounds With vs Without Wound-Targeted Revascularization: Preliminary Observations From an 8-Year Prospective Dual-Center Registry

2019 ◽  
Vol 27 (1) ◽  
pp. 20-30 ◽  
Author(s):  
Vlad-Adrian Alexandrescu ◽  
Sophie Brochier ◽  
Augustin Limgba ◽  
Severine Balthazar ◽  
Hafid Khelifa ◽  
...  
Keyword(s):  
Wound Healing ◽  
Limb Salvage ◽  
Foot Ulcers ◽  
Diabetic Patients ◽  
Technical Success ◽  
Free Survival ◽  
Limb Preservation ◽  
The Mean ◽  
Mean Time

Purpose: To assess the clinical efficacy of endovascular angiosome-oriented wound-targeted revascularization (WTR) vs indirect (wound-indifferent) revascularization (IR) in diabetic patients with neuroischemic foot ulcers. Materials and Methods: Between April 2009 and July 2017, 167 diabetic patients (mean age 72.8 years; 137 men) with chronic limb-threatening ischemia (Rutherford category 5) and foot wounds (Wagner 2–4) in 194 limbs were prospectively registered and scheduled for primary infragenicular endovascular treatment. Specific angiosome source artery reperfusion sustained by patent foot arches or arterial-arterial connections was attempted initially. If this approach failed, topographic revascularization via available collaterals (WTRc) and IR were sequentially attempted. Results: Reperfusion was successful in 176 (91%) of 194 limbs (113 with WTR, 28 with WTRc, and 35 with IR); the global angiosome-oriented technical success (WTR and WTRc) was 73% (141/194). The mean follow-up was 10.9±0.7 months (range 3–12.5). Over 1 year, 102 (58%) of the 176 successfully treated limbs experienced wound healing [79/113 (70%) in the WTR group, 15/28 (54%) in the WTRc group, and 7/35 (20%) in the IR group; p=0.011]. The mean time to healing was 6.8±0.4 months in the WTR group, 7.9±0.6 months in the WTRc group, and 9.8±0.7 months in the IR group (p=0.001). Relapses were noted in 18 (16%) WTR limbs, 5 (18%) WTRc limbs, and 6 (17%) IR limbs. Comparison between WTR and IR and WTRc vs IR showed improved cicatrization in the angiosome-oriented groups (p<0.05). Major adverse limb events (MALE) and limb salvage were different between WTR and WTRc and between WTR and IR groups (p<0.05), while WTRc vs IR was not. Amputation-free survival was not influenced by the revascularization strategy (p=0.093). Conclusion: Wound healing in diabetic patients with chronic limb-threatening ischemia appeared to be improved by intentional wound-targeted revascularization, but no uniform benefit concerning MALE or limb preservation was observed. IR still represents an alternative for limb salvage in cases in which angiosome-guided revascularization fails.

Combination of Open Subtotal Calcanectomy and Stabilization With External Fixation as Limb Salvage Procedure in Hindfoot-Infected Diabetic Foot Ulcers

2016 ◽  
Vol 15 (4) ◽  
pp. 332-337 ◽  
Author(s):  
Luca Dalla Paola ◽  
Anna Carone ◽  
Giulio Boscarino ◽  
Giuseppe Scavone ◽  
Lucian Vasilache
Keyword(s):  
External Fixation ◽  
Limb Salvage ◽  
Therapeutic Option ◽  
Major Amputation ◽  
Healing Time ◽  
Diabetic Patients ◽  
Dermal Substitute ◽  
Salvage Procedure ◽  
Split Thickness Skin Grafting

Diabetic hindfoot ulcers, complicated by osteomyelitis, are associated with a high risk of major amputation. Partial calcanectomy, preceded by an effective management of the infection and of the eventual peripheral artery disease, can be considered as valid therapeutic option. We have evaluated a therapeutic protocol for diabetic hindfoot ulcers complicated by osteomyelitis, which, besides an adequate surgical debridement, considers a reconstructive pathway assisted by the positioning of a circular external fixator. We made a prospective study of a cohort of diabetic patients affected by heel ulcer complicated by osteomyelitis. All patients underwent open partial calcanectomy associated with the positioning of a circular external frame specifically designed for hindfoot stabilization and offloading. A reconstructive procedure was implemented starting with the application of negative pressure wound therapy and coverage with dermal substitute and split thickness skin grafting. From November 2014 to November 2015, 18 consecutive patients were enrolled. Mean follow-up period was 212.3 ± 64.0 days. Healing was achieved in 18 (100%) patients. The mean healing time was 69.0 ± 64.0 days. No major amputation had to be performed during the follow-up. Open partial calcanectomy associated with external fixation and skin reconstruction was as efficient as limb salvage in patients with infected lesions of the hindfoot complicated by calcaneal osteomyelitis.

scholarly journals Limb salvage in diabetics with foot ulcers

1989 ◽  
Vol 13 (2) ◽  
pp. 100-103 ◽  
Author(s):  
K. Larsen ◽  
P. Holstein ◽  
T. Deckert
Keyword(s):  
Limb Salvage ◽  
Main Part ◽  
Major Amputation ◽  
Foot Ulcers ◽  
Diabetic Patients ◽  
Invasive Infection ◽  
Recurrent Ulcer ◽  
Foot Deformity ◽  
Loss Of Limbs ◽  
Neuropathic Ulcers

The healing results in 491 ulcers in 272 diabetic patients are reported. Soft moulded insoles and shoe corrections were the main part of the therapy. There were 329 (67%) neuropathic, 87 (17%) traumatic, 44 (9%) ischaemic and 31 (6%) ulcers of other various pathogenesis. Thirty seven per cent of the ulcers were complicated with invasive infection. Within the period of observation of 18 months (3-39 months) healing was obtained in 79% of the patients (88% of the ulcers) and major amputation was carried out in 8% (4% of the ulcers). There were 21 major amputations, which in 18 cases was due to ischaemia. Thus in only 3 cases (1% of the patients) neuropathy as complicated by invasive infection caused major amputation. Fifty nine ulcers (12%) were classified as relapsing ulcers or ulcers with new localizations and were caused by severe deformity of the foot (58 cases) often in combination with neglect of prophylaxis (7 cases). Only one recurrent ulcer was caused by ischaemia. The series shows that shoe corrections and insoles are effective in treating diabetic neuropathic ulcers. Recurrent ulcerations are caused by severe foot deformity and neglect of therapy. Loss of limbs is caused by ischaemia and invasive infection.

scholarly journals Healing below the ankle is possible in patients with diabetes mellitus and a forefoot gangrene

2021 ◽  
Vol 9 ◽  
pp. 205031212110291
Author(s):  
Targ Elgzyri ◽  
Jan Apelqvist ◽  
Eero Lindholm ◽  
Hedvig Örneholm ◽  
Magdalena Annersten Gershater
Keyword(s):  
Diabetic Foot ◽  
Clinical Characteristics ◽  
Foot Ulcer ◽  
Major Amputation ◽  
Severe Form ◽  
Foot Ulcers ◽  
Vascular Intervention ◽  
Co Morbidity ◽  
Patients With Diabetes

Background: Forefoot gangrene in patients with diabetes is a severe form of foot ulcers with risk of progress and major amputation. No large cohort studies have examined clinical characteristics and outcome of forefoot gangrene in patients with diabetes. The aim was to examine clinical characteristics and outcome of forefoot gangrene in patients with diabetes admitted to a diabetic foot centre. Methods: Patients with diabetes and foot ulcer consecutively presenting were included if they had forefoot gangrene (Wagner grade 4) at initial visit or developed forefoot gangrene during follow-up at diabetic foot centre. Patients were prospectively followed up until final outcome, either healing or death. The median follow-up period until healing was 41 (3–234) weeks. Results: Four hundred and seventy-six patients were included. The median age was 73 (35–95) years and 63% were males. Of the patients, 82% had cardiovascular disease and 16% had diabetic nephropathy. Vascular intervention was performed in 64%. Fifty-one patients (17% of surviving patients) healed after auto-amputation, 150 after minor amputation (48% of surviving patients), 103 had major amputation (33% of surviving patients) and 162 patients deceased unhealed. Ten patients were lost at follow-up. The median time to healing for all surviving patients was 41 (3–234) weeks; for auto-amputated, 48 (10–228) weeks; for minor amputated, 48 (6–234) weeks; and for major amputation, 32 (3–116) weeks. Conclusion: Healing without major amputation is possible in a large proportion of patients with diabetes and forefoot gangrene, despite these patients being elderly and with extensive co-morbidity.

Outcomes after Emergency Admission with a Diabetic Foot Attack Indicate a High Rate of Healing and Limb Salvage But Increased Mortality: 18-Month Follow-up Study

2020 ◽  
Author(s):  
Erika Vainieri ◽  
Raju Ahluwalia ◽  
Hani Slim ◽  
Daina Walton ◽  
Chris Manu ◽  
...  
Keyword(s):  
Limb Salvage ◽  
Diabetic Foot ◽  
Emergency Admission ◽  
Arterial Disease ◽  
Major Amputation ◽  
Outcome Data ◽  
High Rate ◽  
Free Survival ◽  
Peripheral Arterial

Abstract Aim The diabetic foot attack (DFA) is perhaps the most devastating form of diabetic foot infection, presenting with rapidly progressive skin and tissue necrosis, threatening both limb and life. However, clinical outcome data in this specific group of patients are not available. Methods Analysis of 106 consecutive patients who underwent emergency hospitalisation for DFA (TEXAS Grade 3B or 3D and Infectious Diseases Society of America (IDSA) Class 4 criteria). Outcomes evaluated were: 1) Healing 2) major amputation 3) death 4) not healed. The first outcome reached in one of these four categories over the follow-up period (18.4±3.6 months) was considered. We also estimated amputation free survival. Results Overall, 57.5% (n=61) healed, 5.6% (n=6) underwent major amputation, 23.5% (n=25) died without healing and 13.2% (n=14) were alive without healing. Predictive factors associated with outcomes were: Healing (age<60, p=0.0017; no Peripheral arterial disease (PAD) p= 0.002; not on dialysis p=0.006); major amputation (CRP>100 mg/L, p=0.001; gram+ve organisms, p=0.0013; dialysis, p= 0.001), and for death (age>60, p= 0.0001; gram+ve organisms p=0.004; presence of PAD, p=0.0032; CRP, p=0.034). The major amputation free survival was 71% during the first 12 months from admission, however it had reduced to 55.4% by the end of the follow-up period. Conclusions In a unique population of hospitalised individuals with DFA, we report excellent healing and limb salvage rates using a dedicated protocol in a multidisciplinary setting. An additional novel finding was the concerning observation that such an admission was associated with high 18-month mortality, almost all of which was after discharge from hospital.

Influence of pedal arch quality on 5-year survival and limb salvage in patients with diabetic foot ulcers undergoing peripheral angiography

Vascular ◽  
2021 ◽  
pp. 170853812110320
Author(s):  
Nicola Troisi ◽  
Azzurra Guidotti ◽  
Filippo Turini ◽  
Renzo Lombardi ◽  
Francesca Falciani ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Overall Survival ◽  
Renal Failure ◽  
Limb Salvage ◽  
Foot Ulcers ◽  
Diabetic Patients ◽  
Diabetic Foot Ulcers ◽  
Peripheral Angiography ◽  
Kaplan Meier ◽  
Artery Disease

Introduction The aim of this study was to evaluate the influence of pedal arch quality on 5-year survival and limb salvage in diabetic patients with foot wounds undergoing peripheral angiography. Methods Between January 2014 and December 2014, 153 diabetic patients with foot wounds underwent peripheral angiography. Final foot angiograms were used to allocate patients according to pedal arch: complete pedal arch (CPA), incomplete pedal arch (IPA), and absent pedal arch (APA). Five-year survival and limb salvage rates were analyzed with Kaplan–Meier curves and compared by means of Gehan–Breslow–Wilcoxon test. Associations of patient and procedure variables with overall survival and limb salvage outcomes were sought with univariate and multivariate analyses. Results A below-the-knee (BTK) artery was the target vessel in 80 cases (52.3%). Five-year Kaplan–Meier rates of survival were similar in all groups ( p = 0.1): CPA 30%, IPA 27.5%, and APA 26.4%. Five-year limb salvage rates were significantly better in patients with CPA/IPA ( p < 0.001): CPA 95.1%, IPA 94.3%, and APA 67.3%. In the whole population study, multivariate analysis showed significant association of smoking ( p = 0.01), chronic renal failure ( p = 0.02), and severity of foot wounds ( p < 0.001) with survival. Coronary artery disease ( p = 0.03), severity of foot wounds ( p = 0.001), and pedal arch status ( p = 0.05) showed strong association with limb salvage. Conclusions Pedal arch quality significantly affected limb salvage but not survival at 5 years in patients with diabetic foot ulcers. Smoking, chronic renal failure, and severity of foot wounds affected overall survival, whilst coronary artery disease, and severity of foot wounds limb salvage.

Autologous Skin Fibroblast and Keratinocyte Grafts in the Treatment of Chronic Foot Ulcers in Aging Type 2 Diabetic Patients

2011 ◽  
Vol 101 (1) ◽  
pp. 55-58 ◽  
Author(s):  
Matteo Monami ◽  
Maria Vivarelli ◽  
Carla Maria Desideri ◽  
Giulio Ippolito ◽  
Niccolò Marchionni ◽  
...  
Keyword(s):  
Healing Time ◽  
Lower Limbs ◽  
Foot Ulcers ◽  
Diabetic Patients ◽  
Consecutive Series ◽  
Type 2 Diabetic Patients ◽  
Skin Cell ◽  
Type 2 Diabetic

Background: We assessed the tolerability and efficacy of autologous skin cell grafts in older type 2 diabetic patients with chronic foot ulcers. Methods: Treatment with Hyalograft 3D and Laserskin Autograft was proposed to a consecutive series of type 2 diabetic patients older than 65 years affected by long-standing (&gt;6 months) foot ulcers with an area greater than 15 cm2. Ulcer healing rates and measurements of ulcer area were determined monthly for 12 months. Results: Seven patients with 12 ulcers, nine of which received the described treatment, were enrolled. During 12-month follow-up, all of the ulcers healed except one. In the remaining eight ulcers, the median healing time was 21 weeks (interquartile range, 4–29 weeks). Conclusions: Autologous skin cell grafts are feasible, well tolerated, and apparently effective in the treatment of diabetic ulcers of the lower limbs in advanced age. Age did not seem to moderate healing times. (J Am Podiatr Med Assoc 101(1): 55–58, 2011)

scholarly journals Limb Salvage and Functional Outcomes following Free Tissue Transfer for the Treatment of Recalcitrant Diabetic Foot Ulcers

2018 ◽  
Vol 35 (02) ◽  
pp. 117-123 ◽  
Author(s):  
Jocelyn Lu ◽  
Michael DeFazio ◽  
Chrisovalantis Lakhiani ◽  
Michel Abboud ◽  
Morgan Penzler ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Limb Salvage ◽  
Diabetic Foot ◽  
Functional Outcomes ◽  
Free Tissue Transfer ◽  
Major Amputation ◽  
Foot Ulcers ◽  
Diabetic Foot Ulcers ◽  
Flap Survival ◽  
Foot Reconstruction

Background Recent evidence documenting high success rates following microvascular diabetic foot reconstruction has led to a paradigm shift in favor of more aggressive limb preservation. The primary aim of this study was to examine reconstructive and functional outcomes in patients who underwent free tissue transfer (FTT) for recalcitrant diabetic foot ulcers (DFUs) at our tertiary referral center for advanced limb salvage. Methods Between June 2013 and June 2016, 29 patients underwent lower extremity FTT for diabetic foot reconstruction by the senior author (K.K.E.). In all cases, microsurgical reconstruction was offered as an alternative to major amputation for the management of recalcitrant DFUs. Overall rates of flap survival, limb salvage, and postoperative ambulation were evaluated. The lower extremity functional scale (LEFS) score was used to assess functional outcomes after surgery. Results Overall rates of flap success and lower limb salvage were 93 and 79%, respectively. Flap failure occurred in two patients with delayed microvascular compromise. Seven patients in this series ultimately required below-knee amputation secondary to recalcitrant infection (n = 5), intractable pain (n = 1), and limb ischemia (n = 1). The average interval between FTT and major amputation was 8 months (r, 0.2–15 months). Postoperative ambulation was confirmed in 25 patients (86%) after a mean final follow-up of 25 months (r, 10–48 months). The average LEFS score for all patients was 46 out of 80 points (r, 12–80 points), indicating the ability to ambulate in the community with some limitations. Conclusion FTT for the management of recalcitrant DFUs is associated with high rates of reconstructive success and postoperative ambulation. However, several patients will eventually require major amputation for reasons unrelated to ultimate flap survival. These data should be used to counsel patients regarding the risks, functional implications, and prognosis of microvascular diabetic foot reconstruction.

The diabetic foot

2011 ◽  
pp. 1976-1989
Author(s):  
Michael Edmonds ◽  
Alethea. Foster
Keyword(s):  
Diabetic Foot ◽  
Early Recognition ◽  
Treatment Plan ◽  
Staging System ◽  
Major Amputation ◽  
Foot Ulcers ◽  
Diabetic Patients ◽  
Tissue Destruction ◽  
National Guidelines ◽  
International Consensus

At some time in their life, 15% of people with diabetes develop foot ulcers, which are highly susceptible to infection. This may spread rapidly leading to overwhelming tissue destruction and amputation: indeed, 85% of amputations are preceded by an ulcer and there is an amputation in a person with diabetes every 30 seconds throughout the world (1). Evidence-based protocols for diabetic foot ulcers have been developed (2), and diabetic foot programmes that have promoted a multidisciplinary approach to heal foot ulcers with aggressive management of infection and ischaemia have achieved a substantial decrease in amputation rates (3, 4). Furthermore, a reduction in amputations has been reported nationwide in diabetic patients throughout the Netherlands (5). Recently, a decrease in major amputation incidence has been reported in diabetic as well as in nondiabetic patients in Helsinki (6). These reports have stressed the importance of early recognition of the ‘at-risk’ foot, the prompt institution of preventive measures, and the provision of rapid and intensive treatment of foot infection and also evascularization in multidisciplinary foot clinics. Such measures can reduce the number of amputations in diabetic patients. Systematic reviews on prevention and treatment have been carried out, e.g. see Eldor et al. (7), and national guidelines have recently been formulated (8, 9). An International Consensus developed in 1999 was re-launched in revised form as an interactive DVD (10, 11) in 2007. This chapter outlines a simple classification of the diabetic foot into the neuropathic and neuroischaemic foot. It then describes a simple staging system of the natural history of the diabetic foot and a treatment plan for each stage. Successful management of the diabetic foot needs the expertise of a multidisciplinary team which should include physician, podiatrist, nurse, orthotist, radiologist, and surgeon working closely together, within the focus of a diabetic foot clinic.

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