Diabetic Foot Amputation Research Articles

Expression and significance of caveolin-1 in femoral nerve of diabetic foot amputation patients

Objective To investigate the expression and significance of caveolin-1 in femoral nerve of diabetic patients with foot amputation. Methods Forty patients with foot amputation were assigned to 3 groups according to their duration of type 2 diabetes: group A ( ＜6 years＝, group B (6-10 years), and group C ( ＞10 years). Hematoxylin and eosin (HE) stain and Weil's stain were used to examine the femoral nerve. Silver staining was used to observe the axons and to count the nerve fiber density. The expression of caveolin-1 in Schwann cells of femoral nerve was tested by immunohistochemisty. Results There were evident progressive pathological changes in femoral nerve in the 3 groups. The variance of nerve fiber density in the 3 groups reached statistical significance ( P＜0. 05 ＝, the nerve fiber density showed negative correlation with HbA1C( r =-0. 792, P＜0. 01 ＝ and duration ( r=-0.592, P＜0. 01 ＝. The expression of caveolin-1 in Schwann cells of femoral nerve was positive in all the 3 groups and the variance with statistical significance (P＜0. 01 ), it was negatively correlated with HbA1C (r=-0. 762, P＜0. 01 )and duration (r=-0. 532, P＜0. 01 ), and it was positively correlated with nerve fiber density (r=0. 721, P＜0.01 ), the partial correlation coefficient of caveolin-1 and HbA1Cwas-0. 505 ( P＜0. 01 ).Conclusion In patients with diabetic foot amputation, caveolin-1 may play a role in the development of diabetic peripheral neuropathy and diabetic foot. Key words: Caveolin-1; Diabetic foot; Diabetic peripheral neuropathy; Femoral nerve; Diabetes mellitus, type 2

Candida Glabrata Fungemia After Amputation of an Infected Diabetic Foot

A 58-year-old woman suffered from left pyelonephritis with diabetic triopathy on admission at which time a double J stent was inserted in the left ureter and was left untreated for a year. She was admitted due to fever, thirst, polydipsia, polyuria and, left 1,2-toe ulcer and vacuole. We diagnosed diabetic foot infections. We used 6g of ampicillin-sulbactum and 40μg of alprostadil alfadex daily in addition to diet and insulin therapy for diabetes mellitus. As the toe lesion deteriorated, a left foot amputation was performed at the 11th day. The subfever continued and the consciousness level deteriorated from alert to 100 on the Japan coma scale and acute respiratory failure occurred 21 days after operation. Whole body computed tomography showed invasive lesions in bilateral pulmonary lower lobes and renal pelvic dilatation and perirenal abscess in left kidney indicating renal abscess. Milk-like urine was excreted. Urine and blood culture detected Candida glabrata. Fundoscopic exam showed retinal exudates indicating mycotic endophthalmitis. We diagnosed candida glabrata sepsis from pyelonephritis. After using 200mg of micafungin daily, the patient recovered. In addition to exchanging the stent, treatment of diabetes mellitus is important for the prevention of severe infection.

Attention to the diagnosis and treatment of peripheral artery disease is essential in reducing diabetic foot ulcer and amputation

Peripheral artery disease(PAD)is one of diabetic macrovascular complications,with characteristics of being more distal.segmental and extensive.The clinical manifestation of PAD is usually not noticed,and thus diagnosis easily missed.However,PAD is a main cause of diabetic foot and amputation,which would be diagnosed relatively easily if due attention is paid to artery pulse,ankle-brachial blood pressure index,and skin temperature.Ultrasound,CT,MR,and digital subtraction angiography(DSA)examinations are quite useful tools in diagnosis of PAD.The treatment of PAD,including medical and surgical intervention,has been developing quickly.Therapy with stem cell transplantation has been tested in some clinics. Key words: Diabetes mellitus; Peripheral artery diseases; Diabetic foot

Independent risk factors for amputation in diabetic foot

BACKGROUND:Diabetic foot (DF) is the main cause of nontraumatic lower extremity amputation. Early recognition and management of risk factors for foot complications may prevent amputations and other adverse outcomes.MATERIALS AND METHODS:At our hospital we have a protocol for the management of patients hospitalized because of DF. We collected clinical and laboratory data, details of diabetes complications, and history of comorbidities in 146 patients who were admitted for management of DF to determine the risk factors of amputation (major or minor) in these patients. We divided these patients into two groups, those whose treatment included amputation and those who were treated conservatively and carried out a comparative analysis of the variables in the two groups.RESULTS:Major amputation was performed in 5.5% of the patients and minor amputation in 22.6%. Those who required amputation presented a significantly higher (P < 0.05) incidence of nephropathy, history of previous amputation, ischemic diabetic foot and first fasting blood glucose (FBG) > 200 mg/dl after admission. Multivariable-adjusted odds ratios in stepwise logistic regression model was 2.64 for nephropathy (95%CI: 1.06 to 6.60; P = 0.03); 3.03 for ischemic diabetic foot (95%CI: 1.28 to 7.18; P = 0.01); and 3.01 for first FBG > 200 after admission (95%CI: 1.32 to 6.83; P= 0.01).CONCLUSION:Nephropathy, ischemic diabetic foot, and first FBG > 200 mg/dl are independent predictors of limb amputation in patients hospitalized for DF lesions. In addition to early detection and treatment of foot lesions, early management of risk factors is also important.

Promoting Primary Healing after Ray Amputations in the Diabetic Foot: The Plantar Dermo-Fat Pad Flap

Amputation of the toe at the level of the distal metatarsal head (ray amputation) is a common surgical procedure in diabetic foot ulcers. The aim of this study was to introduce a new technique promoting primary healing by minimizing the dead space with the plantar dermo-fat pad flap after central ray amputation in diabetic foot ulcers. Thirty-eight patients who had undergone central ray amputation and closure with the plantar dermo-fat pad flap between 1996 and 2003 were incorporated into the study. The mean follow-up period was 3.56 years. Single and multiple middle toe amputations were performed in 33 and five cases, respectively. In 14 cases with acute infection, split-thickness skin graft was used with the plantar dermo-fat pad flap to close the defect on the foot dorsum. Healing time was uneventful in all patients except three (8 percent), who were healed with local wound care. No patient showed signs of ulceration at the operative site during the follow-up. The mean time to total healing was 40.31 +/- 34.56 days. The plantar dermo-fat pad flap promotes primary wound healing after central ray amputation in diabetic foot ulcers by filling the dead space. The osteotomy to the base of the remaining adjacent metatarsal base in an effort to close the defect can be avoided by using the plantar dermo-fat pad flap; thus, undesirable angulation of the remaining parts of the foot can be eliminated. The plantar dermo-fat pad flap also supports the weak articular capsule of the adjacent metatarsophalangeal joints while covering the amputated metatarsal end. The thick, healthy plantar soft tissue advanced up to the width of the deepithelialized area reestablishes a good, tough plantar surface which--in association with the pad effect of the flap--decreases the recurrence rates and provides comfortable ambulation.

Amputation and Mortality in New-Onset Diabetic Foot Ulcers Stratified by Etiology

We offer many thanks to Williams, Price, and Harding for reading our article (1) with interest and for their comments regarding our study in this issue of Diabetes Care (2). In response to the specific points raised, we provide the following replies. 1 ) Patients with new-onset ulcers developing within the past 1 month were included in the study. Our records did not include whether these patients …

Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology.

Foot ulcers and their complications are an important cause of morbidity and mortality in diabetes. The present study aims to examine the long-term outcome in terms of amputations and mortality in patients with new-onset diabetic foot ulcers in subgroups stratified by etiology. Patients presenting with new ulcers (duration <1 month) to a dedicated diabetic foot clinic between 1994 and 1998 were studied. Outcomes were determined until March 2000 (or death) from podiatry, hospital, and district registers. Baseline clinical examination was done to classify ulcers as neuropathic, ischemic, or neuroischemic. Five-year amputation and mortality rates were derived from Kaplan-Meier survival analysis curves. Of the 185 patients studied, 41% had peripheral vascular disease (PVD) and 61% had neuropathy; 45%, 16%, and 24% of patients had neuropathic, ischemic, and neuroischemic ulcers, respectively. The mean follow-up period was 34 months (range 1-65) including survivors and patients who died during the study period. Five-year amputation rates were higher for ischemic (29%) and neuroischemic (25%) than neuropathic (11%) ulcers. Five-year mortality was 45%, 18%, and 55% for neuropathic, neuroischemic, and ischemic ulcers, respectively. Mortality was higher in ischemic ulcers than neuropathic ulcers. On multivariate regression analysis, only increasing age predicted shorter survival time. All types of diabetic foot ulcers are associated with high morbidity and mortality. The increased mortality appears to be independent of factors increasing ulcer risk-that is, neuropathy and PVD-in patients with established foot ulcers.

Lower limb amputation for diabetic foot.

We amputated 35 limbs of 27 patients with diabetic foot from March 1988 to March 1998. The mean age of the patients at the time of operation was 67 years, and the mean follow-up period was 27 months. Thirteen patients died in the period from 1 day to 39 months after the operation. All patients suffering from diabetic foot were referred to our department for surgical procedures after failure of conservative treatment conducted elsewhere. Their feet were classified into grade 2-3 in 18 limbs, grade 4-5 in 11 limbs, and gangrene of the lower leg and entire foot in 2 limbs, as classified by the Wagner system. Two patients had cellulitis of the foot and two other limbs had infectious gonarthritis. All patients had type 2 diabetes with poor blood sugar control, and 90% were treated by insulin. All patients suffered from diabetic neuropathy. Half of the patients were put on hemodialysis because of diabetic nephropathy. More than 60% of the patients suffered from arteriosclerosis obliterans. The amputation level of the limb was determined by skin thermography, but the patient's will was critical. The initial amputation levels were: débridement and synovectomy in 4 limbs, toe and digital ray in 15 limbs, transmetatarsal in 3 limbs, transtibial in 9 limbs, transfemoral amputations in 4 limbs. Upper level reamputation was conducted on 15 limbs. Logistic regression analysis revealed that lower temperature of the amputation site, being female, and being elderly were significant risk factors in reamputation. Skin thermography was one of the effective determinants of amputation level, in order to avoid reamputation.

Estudio de factores asociados con amputación, en pacientes diabéticos con ulceración en pie

To analyse risk factors for amputation in diabetic foot ulcers. We have studied 152 diabetic patients (in 14 food ulcers treatment was amputation) who were attendance between January 1996 and June 1998 in the diabetic foot Unit. Subjects with gangrene were excluded. Risk factors for amputation were: previous history of amputation (odds ratio 3.7; 1.0113.7), proliferative retinopathy, osteomielitis, and independently clinical signs of peripheral vasculopathy (7.1; 1.88-27.2) and severe infection (14.4; 2.92-71.2). Diabetic subjects with foot ulcers and previous history of amputation, proliferative retinopathy, osteomielitis, clinical signs of peripheral vasculopathy and/or severe infection were a high risk group for amputation and in this group aggressive therapeutical and preventive approaches should be done in order to prevent amputation.

What is the most effective way to reduce incidence of amputation in the diabetic foot?

What is the most effective way to reduce incidence of amputation in the diabetic foot?