Diabetic Foot Clinic Research Articles

Early Treatment of Acute Stage 0/1 Diabetic Charcot Foot Can Avoid Major Amputations at One Year.

Background: If unrecognized, Charcot neuro-osteoarthropathy (CNO) can be a devastating complication of diabetes. Methods: The aim of this retrospective study was to evaluate the outcomes in a cohort of diabetic patients diagnosed with active CNO managed in a tertiary level diabetic foot clinic (DFC). We included consecutive patients with active CNO, stage 0-1, according to the Eichenholtz-Shibata classification, who were referred from 1 January 2019 to 27 September 2022. Diagnosis of CNO was based on clinical signs and imaging (X-rays and magnetic resonance). All patients were completely offloaded by a total-contact cast (TCC) or removable knee-high device. Each patient was closely monitored monthly until CNO remission or another outcome. At 12 months of follow-up, the following outcomes were analyzed: remission, time to remission, major amputations (any above the ankle), and surgical indication. Results: Forty-three patients were included. The mean age was 57.6 ± 10.8 years; 65% were males and 88.4% had type 2 diabetes, with a mean duration of 20.6 ± 9.9 years. At baseline, 32.6% was affected by peripheral artery disease. Complete remission was recorded in 40/43 patients (93%), with a mean time to remission of 5.6 ± 1.5 months; major amputation and surgical indication occurred, respectively in 1/43 patients (2.3%) and 3/43 patients (7%). Conclusions: Early treatment of active Stage 0/1 CNO leads to high rates of remission and limb salvage.

Bottom-up approach to build a ‘precision’ risk factor classification for diabetic foot ulcer healing. Proof-of-concept

AimsDiabetic foot ulcers (DFU) have a complex multifactorial pathophysiology. It is crucial to identify essential prognostic variables to streamline therapeutic actions and quality-of-care audits. Although SINBAD and University of Texas (UT), the most frequently used prognostic classification systems, were prospectively validated, not all individual parameters were shown to have consistent associations with healing. In this study, we used a bottom-up approach relying on robust methods to identify independent predictors of DFU healing. Methods1,664 DFU patients were included by 34 Belgian diabetic foot clinics (DFCs). Twenty-one patient- and foot-related characteristics were recorded at presentation. Predictors of healing were identified using multivariable Cox proportional hazard regression. Multivariable models were built using backward regression with multiple imputation of missing values and bootstrapping. ResultsFive essential independent variables were identified: presentation delay, history of minor amputation, ulcer location, surface area and ischemia. This 5 variable-model showed a better performance compared to models based on existing classification systems. ConclusionsA bottom-up approach was used to build a prognostic classification for DFU healing based on large databases. It offers new insights and allows to tailor the classification to certain clinical settings. These 5 parameters could be used as a ‘precision classification’ for specialized DFCs.

Factors determining the risk of diabetes foot amputations – A retrospective analysis of a tertiary diabetes foot care service

AimsTo identify which factors predict the need for minor or major amputation in patients attending a multidisciplinary diabetic foot clinic (DFC). MethodsA retrospective analysis of patients who attended over a 27 month period were included. Patients had to have attended ≥3 consecutive consultant led clinic appointments within 6 months. Data was collected on HbA1c, clinic attendance, blood pressure, peripheral arterial disease (PAD), and co-morbidities. Patients were followed up for 1 year. Results165 patients met the inclusion criteria. 121 were male. 33 patients had amputations. There was an association between poor glycaemic control at baseline and risk of amputation when adjusted for other factors, with those patients having HbA1c ≤58mmol/mol (7.5%) at less risk of amputation with an odds of 0.14 (0.04–0.53) of amputation(p=0.0036). Other statistically significant factors predictive of amputation were: missing clinic appointments (p=0.0079); a high Charlson index (p=0.03314); hypertension (p=0.0216). No previous revascularisation was protective against amputation (p=0.0035). However PAD was not seen to be statistically significant, although our results indicated a lower risk of amputation with no PAD. Overall, 34.9% (n=58) of patients had good glycaemic control (HbA1c <58mmol/mol, [7.5%]) at baseline and 81.3% (n=135) had improved their glycaemic control at their last follow up appointment. ConclusionsIn this cohort poor glycaemic control, poor attendance, previous revascularisation and hypertension were associated with higher risk of amputation, with PAD showing a trend. Moreover, we demonstrated benefits in glycaemic control achieved by attending this DFC, which is likely to translate to longer term diabetes related health benefits.

The Multidisciplinary Diabetic-Foot Clinic

need easy access to this system, which should provide specialized care. Such clinics were set up in the United Kingdom in 1980s. The main principles of care were regular debridement, early and aggressive treatment of infection, custom-made footwear, and education. The clinics were permanent bases for clinical assessment, investigation and regular treatment, and a focal point for patients who were seen by several members of the team at one visit. The clinics were easily accessible for both urgent consultations and regular outpatient treatment. They quickly reduced amputations by approximately 50%. Indeed, this benchmark of improvement was incorporated into the St Vincent Declaration in Europe as one of the proposed targets of improved health care in diabetes. In United Kingdom, a working party between the department of health and the then British Diabetic Association provided a strategy document supporting the development of multidisciplinary foot clinics in hospitals, as well as stressing the importance of education and screening in the community. Throughout the 1990s, the number of hospital multidisciplinary diabetic-foot clinics increased as did the challenges they faced. Provision was made for open access so that patients could attend quickly when they developed lesions. It was important for diabetic-foot care to be coordinated and not fragmented. At King’s College Hospital, the post of hospital diabetic-foot practitioner was set up to coordinate care of the diabetic-foot inpatient between various hospital specialities and also to link community services when patients were discharged. The multidisciplinary clinics also faced increasing clinical challenges, stretching into the 21st century, including the ischemic foot, the Charcot foot, and the renal foot. Patients with diabetes were surviving longer, and distal arterial disease posed a major problem for management. However, multidisciplinary clinics embraced the skills and technologies of the interventional radiologists, and the vascular surgeon and numbers of amputations continued to The diabetic-foot patient is very vulnerable. There is a rapidly progressive and complex natural history that demands easily accessible, specialized multidisciplinary and coordinated care. This is necessary both in the short term and in the long term. It is important to understand this vulnerability and devastating natural history so as to organize efficient care. Three major pathologies come together in the diabetic foot, neuropathy, immunopathy, and ischemia. The impact of neuropathy in the diabetic foot is immense. Signs and symptoms of disease may be minimal; however, the pathology proceeds rapidly, and the end stage of tissue death is quickly reached. Therefore, the window of opportunity is limited. Furthermore, the immune system, which serves as a sixth sense, is also deficient. An intact inflammatory response notifies the nervous system of the presence of bacteria. In diabetes, both the immune system and the nervous system are deficient, and the body is unaware of bacterial invasion. Peripheral arterial disease occurs distally, is difficult to treat, and is accompanied by coronary artery and cerebrovascular disease. In diabetes, there is also microvascular component of ischemia leading to nephropathy and retinopathy. Such vulnerability is also increased by poor socioeconomic circumstances and poverty. This overwhelming vulnerability leads to devastating natural history with rapid progression from ulceration to infection, leading to gangrene both in the neuropathic and neuroischemic foot. To detect this problem and intervene early and also reverse the natural history, a unique special form of health care is necessary. This is the multidisciplinary team working together in a dedicated diabetic-foot clinic. Patients The International Journal of Lower Extremity Wounds Volume 7 Number 2 June 2008 66-67 © 2008 Sage Publications 10.1177/1534734608317638 http://ijlew.sagepub.com hosted at http://online.sagepub.com