May 17, 2013 - greater circumferential distance of left lower leg was also noted .... Modified Charles procedure using negative pressure dressings for primary ...
transmetatarsal amputation. Digital amputations of the forefoot may seem routine. Lesser digital am- putations have successful outcomes of greater than 90%.12 ...
Dec 30, 2014 - Methods: Between April 2004 and July 2013, 154 patients underwent limb salvage surgery for distal diabetic foot gangrene. According to the ...
Type II diabetic patients being treated for chronic foot ulcers and in receipt of regular antidiabetic treatment were recruited from the orthopaedic units of two ...
Diabetic patients frequently suffer from foot ulcer. In spite ... of diabetic ulcer using Chinese herbal medicine. .... Since the ulcers (with or without gangrene of the.
Data Synthesis Prevention of diabetic foot ulcers begins with screening for loss ..... vascular disease, history of foot ulcer or amputation, or severe nail pathology.
ic denervation, dry skin, and warm feet. ... present in almost two thirds of patients with foot ulcers.4 Inappropriate footwear is the .... appropriate shoes and.
and Treatment of Diabetic Foot Ulcers ... Diabetic foot ulcers are associated with decreased quality .... and/or large vessel disease, but most commonly DFUs.
Nov 2, 2009 - diabetes.1 Diabetic foot ulcers (DFUs), one of the most com- mon complications of diabetes, ... insufficiency.1,3,4,6,7 DFUs are often recalcitrant to treatment .... substantially after accounting for cardiovascular disease, microal-.
The pathogenesis of foot ulceration is complex, clinical presentation variable, and management ... disease, and other complications of diabetes common to.
31,000 individuals with a diabetic neuropathic foot ulcer seen in the Curative Health ... new treatment classes, growth factors and ... limb arterial disease.
Feb 13, 2017 - Military Area Command of Chinese PLA, Jinan 250000, .... 19/F/29. IB. 1. 5.4. +. 20/M/13. IIB. 4. 17.2. +. 21/M/34. IIA. 4. 9.9. +. 22/F/21. IIB. 4. 9.6.
Nov 6, 2009 - OBJECTIVE: Prediction of diabetic foot ulcer outcome may be helpful for clinicians in opti- mizing and ... Older age, presence of coronary artery disease, smoking and ulcer .... Treatment consisted of daily wound care, bed rest,.
evaluation, surgical technique and the technology of mate- rials and implants. Complications, however, such as deep infection, fracture, bone resorption, and ...
Articular resections represent the most complex reconstruction problem in oncologic surgery. Three forms of ... for custom prosthetic manufacturing and articular degeneration, and allowing for soft- tissue attachment. ... Cara JA, Amillo S, CaÃ±adell
45 results - The search term used included mangled lower extremity, MESS, PSI, LSI and ... score shows better results when applied to type III tibial fractures.
to insensitive feet since. Bibli- cal times. They are usually described as trophic ulcers; this implies some abnormality of nutrition of the skin and underlying tissues ...
Apr 11, 2012 - Regardless of the method of fixation to the host bone, the prosthesis may loosen over time. Mechanical ... Rebushing is required more commonly in the fixed hinge implant and generally .... manual labour. ... The principles ..... Applic
compared with hemipelvectomy and its resultant disability. These extensive procedures, however, are associated with significant morbidity and a high incidence ...
revascularizations were for limb/foot salvage. Partial amputation of the foot (such as toe or transmetatarsal amputation) with retention of a sufficiently functional.
HighBeam Research | The Diabetic Foot | 12/22/2005. LOW-LEVEL LASER THERAPY FOR DIABETIC FOOT WOUND HEALING. (WOUND CARE). Houreld ...
where antibiotic beads along with the infected knee prosthesis were removed and an antibiotic cement coated nail spacer was inserted (Figure 2). After few.
Objective: To assess outcomes of percutaneous infrainguinal arterial angioplasty for treatment of .... who underwent revascularization, two have died, two un-.
co-morbidities, foot ulcer characteristics and treatment were recorded on a standardised form. ... eral arterial disease, pressure overload, trauma and foot.
Prosthetics and Orthotics International,
Limb salvage in diabetics with foot ulcers K. L A R S E N , P. H O L S T E I N and T. D E C K E R T Steno Memorial Hospital, DK2820 Gentofte, Denmark
1980; Larsen et al., 1982; Pollard and Le Q u e s n e , 1983; B u r d e n et al., 1983). T h e present study was u n d e r t a k e n to evaluate healing results and to identify high risk patients as regards recurrent ulceration and risk of amputation.
T h e healing results in 491 ulcers in 272 diabetic patients are r e p o r t e d . Soft moulded insoles and shoe corrections were the main part of the therapy. T h e r e were 329 ( 6 7 % ) neuropathic, 87 ( 1 7 % ) 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 m o n t h s (3-39 months) healing was obtained in 7 9 % of the patients ( 8 8 % of the ulcers) and major amputation was carried out in 8% ( 4 % of the ulcers). T h e r e were 21 major amputations, which in 18 cases was due t o ischaemia. T h u s in only 3 cases ( 1 % of the patients) n e u r o p a t h y 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 t h e foot (58 cases) often in combination with neglect of prophylaxis (7 cases). Only o n e recurrent ulcer was caused by ischaemia. T h e 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.
Patients and methods Patients T h e series is consecutive consisting of 272 patients with 491 ulcers treated in Steno Memorial Hospital from 01.12.79 through 30.11.82. In 204 patients there was unilateral and in 68 bilateral ulcers. Figure 1 shows the age distribution and the t r e a t m e n t of diabetes. A b o u t one third were younger t h a n 50 years, mostly insulin d e p e n d e n t and 48 per cent of the ulcers occurred in patients active in their jobs. Figure 2 shows t h e duration of diabetes mellitus, which in 24 p e r cent was of m o r e than 30 years duration. M a n y of the patients were over-weight (Table 1), although being under weight did not prevent ulceration.
Introduction T h e risk of a m p u t a t i o n in the diabetic patient has b e e n found to b e increased 15 times as compared to the non-diabetic patient (Most and Sinnock 1983). R e c e n t studies, however, suggest that the progressive destruction of the neuropathic or gangrenous foot can b e stopped and the n u m b e r of amputations substantially decreased (Holstein et al., 1976; W a g n e r , 1979; B r a n d , 1979; L i p p m a n n , 1979; R u n y a n et al All correspondence to be addressed to Ms. K. Larsen, Kollelevbakken 14,DK 2830 Virum, Denmark.
Figure 1: Treatment of diabetes and age distribution of patients. 100
Limb salvage in diabetics
Figure 3: Localization of 439 ulcers. The drawing does not include ulcers around the malleoli and ulcers following digital amputations. Figure 2: Treatment of diabetes and duration of the disease. Previous amputations were recorded as follows: o n e above-knee, 20 below-knee and 22 on the toes or on the forefoot. Ulcers Table 2 shows t h e duration of the ulcers before t r e a t m e n t in the present hospital. T h e duration did n o t , however, correlate with t h e healing time. T h e localization of t h e foot ulcers is shown in Figure 3, highlighting the importance of p r o p e r footwear, insoles and protection of t h e heel. T a b l e 3 shows t h e pathogenesis, most ulcers having b e e n caused by repetitive stress ( B r a n d , 1979). Ischaemic ulcers were defined by the finding of a digital Table 1. Bodyweight* and number of ulcers.
blood pressure less than 40 m m H g . Fifty nine ulcers were classified as relapses or new ulcers in previously healed feet. Invasive infection occurred in as m a n y as 37 p e r cent of the ulcers. Methods Two main principles in treating plantar foot ulcers were followed: 1) A b n o r m a l varus or valgus load present in most cases was corrected with modules m a d e from soft materials (3-5 m m R u b a z o t e ) and adjusted to balance t h e foot. 2) A b n o r m a l pressure points were compensated for by pads of the same material. This c o m p o u n d insole was corrected during the course of healing resulting in a final device for p e r m a n e n t use, eventually covered with thin leather. M o r e o v e r , p r o m i n e n t structures, e.g. claw toes were protected with silicone r u b b e r pads. V e n o u s ulcers were treated with zinc paste b a n d a g e followed by compression stockings. M o r e spacious shoes were prescribed whenever necessary, possibly as orthopaedic R
Table 3. Pathogenesis Table 2. Duration of ulcers
K. Larsen, P. Holstein and T. Deckert Table 6. Healing in relation to distal blood pressure
Table 4. Footwear and ulcers
footwear (Table 4). In cases of suspected ischaemia, digital and ankle blood pressures were measured with strain gauge plethysmography. Minor necroses were excised often by r e p e a t e d small revisions without anaesthesia. Digital amputations were d o n e during local anaesthesia in Steno M e m o r i a l Hospital whereas major amputations were d o n e in collaborating hospitals. Invasive infection in the form of osteitis or plantar abscess was treated with surgical drainage s u p p o r t e d by antibiotics according to cultures. G r e a t attention was always paid to blood sugar control. T h e vast majority of t h e series (83 p e r cent) were treated in the out-patient clinic.
Table 7. Relapses and new ulcers
T h e series was evaluated 3 m o n t h s after the end of the period studied yielding a m e a n time of observation of 18 m o n t h s (3-39 m o n t h s ) . O u t of 491 ulcers 88 p e r cent healed, i.e. 79 per cent of the patients (Table 5). T h e healing rate was statistically significant correlated with digital as well as ankle blood pressures (Table 6). Healing of ulcers was not related t o their localization. Eight per cent of t h e patients had major amputation below the k n e e , i.e. in four per cent of the ulcers. Of these 21 amputations 18 were caused by ischaemia and three by infection originating from heel necrosis. Vascular reconstruction was only a t t e m p t e d in one ischaemic limb and was not successfull.
T h e localization of t h e ulcers in the present series is similar to that d e m o n s t r a t e d in leprosy patients (Languillon, 1964) the c o m m o n d e n o m i n a t o r being the insensitive feet. In the t r e a t m e n t of diabetic n e u r o p a t h i c foot ulcers two different principles are currently used. In s o m e centres healing is obtained by application of rigid casts ( B r a n d , 1979; W a g n e r , 1979; B u r d e n et al., 1983; J e r n b e r g e r , 1986) and maintained by various shoe systems. In other centres the external pressure is relieved with t h e aid of soft materials which are adjusted during the healing phase (Holstein et al., 1976; Faris, 1982). T h e authors prefer t h e latter principle because pressure necrosis from rigid casts is avoided and the adjusted shoes and insoles provide a p r o p e r prophylaxis against new ulcers—with a shoe cosmesis acceptable to most patients. T h e literature o n diabetic foot lesions is growing, but it is at present difficult to c o m p a r e the results from o n e centre to a n o t h e r and an
Table 7 d e m o n s t r a t e s the pathogenesis of 59 cases of recurrent ulceration found in 46 patients. O n e was ischaemic and 58 were neuropathic, all of these occurring in severely deformed feet. Eight of the patients had neglected the prophylaxis.
Table 5. Healing rate
Limb salvage in diabetics u n t r e a t e d control g r o u p is n o t available. H o w e v e r , t h e compensation for n e u r o p a t h y and t h e aggressive t r e a t m e n t of invasive infection give healing rates, which are c o m p a r a b l e t o those o b t a i n e d in ulceration a n d gangrene in non-diabetic patients (Holstein and Lassen, 1980), a n d these results are confirmed in the p r e s e n t study. This series d e m o n s t r a t e s that soft insoles a n d p r o p e r footwear are a d e q u a t e in preventing major a m p u t a t i o n in n e u r o p a t h i c lesions, b u t these measures were not adequate in preventing n e w ulcers, which occurred in t h e severely d e f o r m e d feet possibly in connection with neglect of prophylaxis. It is possible that a wider u s e of surgical correction of t h e deformities a n d m o r e extensive use of orthotic m e a s u r e s are justified in such cases. Major a m p u t a t i o n s w e r e almost exclusively performed in severe ischaemia w h e r e t h e patients were n o t suitable for vascular reconstruction. H o w e v e r , t h e femoro-crural in situ by-pass ( L e a t h e r et a l . , 1981), h a d n o t yet b e e n introduced in D e n m a r k during t h e period studied. T o d a y a n u m b e r of diabetic patients with ischaemic ulcers a r e effectively t r e a t e d b y this p r o c e d u r e . T h e a n n u a l n u m b e r of major a m p u t a t i o n s in diabetics in D e n m a r k is slowly b u t steadily decreasing. F r o m 560 in 1980 t o 300 in 1986 ( E b s k o v , 1988). This is probably d u e t o an increasing interest in diabetic foot p r o b l e m s , economic support for regular foot control a n d reinforcement of education at all levels. Major attention is paid t o t h e prophylaxis since "if a n ulcer develops ... t h e preventative m e a s u r e s h a v e failed (Faris, 1982)". REFERENCES
JONES, G. R.,
EBSKOV, B . (1988). The dimension of the problem. Paper in "Rehabilitation and prosthetics after amputation on the lower limb". ISPO—symposium, May, Herlev, Denmark. FARIS, I. (1982). The management of the diabetic foot. Churchill Livingstone, 65. HOLSTEIN, P., LARSEN, K. AND SAGER, P. (1976).
Decompression with the aid of insoles in the treatment of diabetic neuropathic ulcers. Acta Orthop. Scand. 47,463-68. HOLSTEIN, P. AND LASSEN, N. A. (1980). Healing of
ulcers on the feet correlated with distal blood pressure measurements in occlusive arterial disease. Acta Orthop. Scand. 51,995-1006. JERNBERGER, A. (1986). Treatment of foot ulcers and gangrene. Presented at V World ISPO Congress. LARSEN, K . , CHRISTIANSEN, J. S. AND EBSKOV, B .
(1982). Prevention and treatment of ulcerations of the foot in unilaterally amputated diabetic patients. Acta Orthop. Scand. 53,481-485. LANGUILLON, J. (1964). Frequency and localization of plantar perforating ulcers of leprosy patients. Lep. Rev. 35,239-249. LEATHER, R. P . , SHAH, D . M. ANDKARMODY, A. M.
(1981). Infrapopliteal arterial by-pass for limb salvage. Increased patency and utilization of the saphenous vein used "in-situ". Surgery 190, 10001008. LIPPMANN, H. I. (1979). Must loss of limb be a consequence of diabetes mellitus? Diabetes Care 2 , 432-436. MOST,
epidemiology of lower extremity amputations in diabetic individuals. Diabetes Care 6, 87-91. NATVIG, H . (1956). Nye høyde-vekt tabeller for norske kvinner og menn. Landsforeningen for kosthold og helse. Oslo Universitet. POLLARD, J. P. AND L E QUESNE, L. P.
Method of healing diabetic forefoot ulcers. Br. Med. J. 2 8 6 , 436-437. RUNYAN, J. W., ZWAAG, R. V . , JOYNER, M. B . ,
BRAND, P. W. (1979). Management of the insensitive limb. Phys. Ther. 5 9 , 8-12. BURDEN, A. C ,
JONES, R. AND
BLANDFORD, R. L. (1983). Use of the "Scotchcast" boot in treating diabetic foot ulcers. Br. Med. J. 14 May, 1555-1557.
MILLER, S. T. (1980). The Memphis Continuing Care Program. Diabetes Care 3 , 382-386. WAGNER, W. F. (1979). A classification and treatment program for diabetic, neuropathic and dysvascular foot problems. A.A.O.S. Instructional course lectures. 28,143-163.