Diabetic foot disease frequently leads to substantial long-term complications, imposing a huge socioeconomic burden on available resources and health-care systems. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common underlying pathways that lead to skin breakdown, often setting the stage for limb-threatening infection. Individuals with diabetes presenting with foot infection warrant optimal surgical management to affect limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. In addition, the initial surgical intervention or series of interventions must be coupled with appropriate systemic metabolic management as part of an integrated, multidisciplinary team. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health-care systems. This article presents a stepwise approach to the diagnosis and treatment of diabetic foot infections with emphasis on the appropriate use of surgical interventions and includes the following key elements: incision, wound investigation, debridement, wound irrigation and lavage, and definitive wound closure. (J Am Podiatr Med Assoc 100(5): 401–405, 2010)
Background: Diabetes-related lower-extremity amputations are largely preventable. Eighty-five percent of amputations are preceded by a foot ulcer. Effective management of ulcers, which leads to healing, can prevent limb loss.
Methods: In a county hospital, we implemented a six-step approach to the diabetic limb at risk. We calculated the frequency and level of lower-extremity amputations for 12 months before and 12 months after implementation of the amputation prevention program. We also calculated the high-low amputation ratio for the years reviewed. The high-low amputation ratio is a quality measure for the success of amputation prevention measures and is calculated as the ratio of the number of high amputations (limb losses) over the number of low (partial foot) amputations.
Results: The frequency of total amputations increased from 24 in year 1 to 46 in year 2. However, the number of limb losses decreased from 7 to 2 (72%). The high-low amputation ratio decreased eightfold in 1 year, which serves as a marker for limb salvage success.
Conclusions: Improvement in care organization and multidisciplinary-centered protocols can substantially reduce limb losses. (J Am Podiatr Med Assoc 100(2): 101–104, 2010)
Previous study indicates that pharmacologic antithrombotic therapy may be an inhibitory factor for wound healing and should merit consideration among the other core factors in wound healing optimization.
This study provides a retrospective analysis of the effect of antithrombotic therapy on wound healing rates of uncomplicated diabetic foot ulcerations. Wounds treated with standard of care in the presence of clinical anticoagulation were compared to control wounds.
The results indicate a statistically significant negative correlation between antithrombotic therapy and diabetic foot wound healing rate. This represents the first study focusing on this correlation in the uncomplicated diabetic foot wound.
This retrospective study demonstrates that antithrombotic therapy has a statistically significant negative effect on healing rates of uncomplicated diabetic foot ulcerations. Both wound area and depth improvement over 4 weeks was significantly better in treated patients who were not on antithrombotic therapy for comorbidity not associated with peripheral arterial disease.
This study evaluated changes in pressure imparted to diabetic foot wounds using a novel negative pressure bridging technique coupled with a robust removable cast walker. Ten patients had plantar pressures assessed with and without a bridged negative pressure dressing on the foot. Off-loading was accomplished with a pressure-relief walker. Plantar pressures were recorded using two pressure-measurement systems. The location and value of peak focal pressure (taken from six midgait steps) were recorded at the site of ulceration. Paired analysis revealed a large difference (mean ± SD, 74.6% ± 6.0%) between baseline barefoot pressure and pressure within the pressure-relief walker (mean ± SD, 939.1 ± 195.1 versus 235.7 ± 66.1 kPa). There was a mean ± SD 9.9% ± 5.6% higher pressure in the combination device compared with the pressure-relief walker alone (mean ± SD, 258.0 ± 69.7 versus 235.7 ± 66.1 kPa). This difference was only 2% of the initial barefoot pressure imparted to the wound. A modified negative pressure dressing coupled with a robust removable cast walker may not impart undue additional stress to the plantar aspect of the foot and may allow patients to retain some degree of freedom (and a potentially reduced length of hospital stay) while still allowing for the beneficial effects of negative pressure wound therapy and sufficient off-loading. (J Am Podiatr Med Assoc 94(5): 456–460, 2004)
The coronavirus disease of 2019 pandemic has disrupted health care, with its far-reaching effects seeping into chronic disease evaluation and treatment. Our tertiary wound care center was specially designed to deliver the highest quality care to wounded patients. Before the pandemic, we were able to ensure rapid treatment by means of validated protocols delivered by a colocalized multidisciplinary team within the hospital setting. The pandemic has disrupted our model’s framework, and we have worked to adapt our workflow without sacrificing quality of care. Using the modified Donabedian model of quality assessment, we present an analysis of prepandemic and intrapandemic characteristics of our center. In this way, we hope other providers can use this framework for identifying evolving problems within their practice so that quality care can continue to be delivered to all patients.
The objective of this investigation was to determine the level of agreement between a systematic clinical Doppler examination of the foot and ankle and diagnostic peripheral angiography.
The described Doppler examination technique attempted to determine the patency, quality, and direction of the flow through the dorsalis pedis artery, posterior tibial artery, terminal branches of the peroneal artery, and vascular arch of the foot. These results were then compared with angiographic distal run-off images as interpreted by a blinded vascular surgeon.
Levels of agreement with respect to artery patency/quality ranged from 64.0% to 84.0%. Sensitivity ranged from 53.8% to 84.2%, and specificity ranged from 64.7% to 91.7%. Agreement with respect to arterial flow direction ranged from 73.3% to 90.5%.
We interpret these results to indicate that this comprehensive physical examination technique of the arterial flow to the foot and ankle with a Doppler device might serve as a reasonable initial surrogate to diagnostic angiography in some patients with peripheral arterial disease.
Background: We used a model of lower-extremity ulceration to determine the impact of a podiatric lead limb preservation team on identified relationships among risk factors, predictors of ulceration, amputation, and clinical outcomes of lower-extremity disease in patients with diabetes mellitus.
Methods: A total of 485 patients with diabetes mellitus were randomly selected from the diabetic population and included in this retrospective cohort study. Patients were then stratified into two groups: those who received specialty podiatric medical care and those who did not. Data covering a 5-year period were collected using electronic medical records and chart abstraction to capture detailed treatment characteristics, ulcer status, and surgical outcomes.
Results: Overall, the frequencies of inpatient and outpatient encounters and the durations of hospital stays were significantly greater with increasing wound depth and in the presence of infection. In addition, the overall ulcer incidence was greater in patients with callus (34.3% versus 10.3%, P < .0001) with and without neuropathy (20.4% and 4.1%, P < .0001). Among patients treated in a specialty multidiscipline podiatric medical setting, the proportion of all amputations that were “minor” was significantly increased (33.7% versus 67.3%, P = .0006), and survival was significantly improved (19.5% versus 7.7%, P < .0001).
Conclusions: Early identification of individuals at increased risk for lower-extremity ulceration and subsequent referral for advanced multidiscipline podiatric medical specialty care may decrease rates of ulceration and proximal amputation and improve survival in patients with diabetes mellitus who are at high risk for ulceration and limb loss. (J Am Podiatr Med Assoc 100(4): 235–241, 2010)
Background: Chronic wounds, especially in patients with diabetes, often represent clinical challenges. Recently, the use of a topically applied blood clot has garnered significant interest. This stromal matrix contains viable cells that are autologous, biocompatible, biological, and consistent with a metabolically active scaffold. It has been shown to be safe, effective, and cost-efficient. However, the mechanism of action of this modality remains elusive. We sought to identify a potential mechanism of action of an autologous blood clot.
Methods: Review of clinical and scientific literature hypothesizes on how autologous blood clots may stimulate healing and facilitate the movement of critical substrates while lowering bioburden and fostering angiogenesis.
Results: Blood serves as a carrier for many components: red blood cells, white blood cells, platelets, proteins, clotting factors, minerals, electrolytes, and dissolved gasses. In response to tissue injury, the hemostatic mechanism uses a host of vascular and extravascular responses initiating primary, secondary, and tertiary hemostasis. The scaffold created by the autologous blood clot tissue provides a medium in which the body can transform the wound from a nonhealing chronic condition into a healing acute condition. The autologous blood clot tissue also creates a protective setting for the body to use its own mechanisms to promote wound healing in an organized manner. This transient scaffold recruits surrounding fibroblasts and promotes cell ingrowth to foster granulation tissue remodeling. Cells in this matrix sense not only soluble factors but also their physical environments. This well-orchestrated mechanism includes signals from soluble molecules, from the substrate/matrix to which the cell is adherent, from the mechanical or physical forces acting on it, and from contact with other cells. Topically applied autologous blood clot tissue can lower bacterial bioburden while stimulating angiogenesis and fostering the movement of keratinocytes and fibroblasts.
Conclusions: Topically applied autologous blood clot tissue is a formidable cellular and tissue-based therapy that has been shown to be safe and effective. Although the central component of this therapy is blood, the autologous clot tissue creates a scaffold that performs as a biological delivery system that functions to control the release of growth factors and cytokines over several days.
Background: Recurrent ulceration is a common problem after partial first-ray amputations. Loss of the first metatarsophalangeal joint contributes to altered biomechanics and increased pressure on the foot. This may increase risk of adjacent ulcerations and additional amputations. Preserving first-ray length maintains the metatarsal parabola and limits transfer lesions, but few data support this. We aimed to evaluate the incidence of ulceration after partial first-ray amputations and to assess the association between metatarsal protrusion distance and recurrent ulceration.
Methods: Thirty-two consecutive patients underwent unilateral partial first-ray amputation at various levels along the first metatarsal, and the metatarsal protrusion distance was measured after surgery. Incidence of ulceration was evaluated on the ipsilateral foot. We hypothesized that patients with a longer first metatarsal were less likely to ulcerate again on the ipsilateral foot.
Results: Fourteen patients (43.8%) ulcerated again after partial first-ray amputation. Mean time to ulceration was 104 days. Active smoking status was associated with increased risk of another ulceration (P = .02), and chronic kidney disease was associated with a decreased risk of recurrent ulceration (P = .03). The average metatarsal protrusion distance for patients who ulcerated again after surgery was 36.1 mm versus 25.9 mm for patients who did not (P = .04). Logistic regression analysis of the receiver operating characteristic curve demonstrated an ideal cutoff length for recurrent ulceration of 37 mm (area under the curve = 0.7381). Patients with a protrusion distance greater than 37 mm were nine times as likely to ulcerate again (95% CI, 1.7–47.0).
Conclusions: Partial first-ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. Unfortunately, these patients are prone to recurrent ulceration. Significant loss of first metatarsal length is a poor prognostic indicator for recurrent ulceration.