Diabetic Foot Complications Research Articles

Evaluation of the Knowledge and Practice about Diabetes Mellitus of Adult Population in Porto Novo (Benin)

Background: Diabetes mellitus is one of the most common non-communicable diseases in the world. The aim of our study was to assess the level of knowledge of the adult population of Porto-Novo on clinical manifestations and complications of diabetes mellitus. Methods: It is a descriptive cross-sectional study conducted under STEP wise approach. It took place from June 1 to July 28, 2014. Results: A total of 240 subjects were included in the study. The mean age of the subjects was 46.07 years ± 12.63 years, ranging from 25 to 80 years. Subjects age between 35 - 45 years are the most represented. Women were mostly represented 162 against 78 men respectively 67.5% against 32.5% with sex ratio of 0.48. The majority of the subjects were scholar (73.3%). For clinical manifestations of diabetes mellitus, 64.2% of subjects had quoted polyuria, asthenia 57.5%, 56.7% weight loss. Polydipsia and polyphagia were less familiar with, respectively, 27.5% and 23.3%. Regarding the complications of diabetes, diabetic foot and coma were the best known, respectively, 78.8% and 58.8%. Nephropathy (45.0%), 39.6% retinopathy and neuropathy (21.7%) were the least known. The prevalence of physical inactivity in this study population was 95.0%. It was 98.1% in women versus 88.5% for men. Conclusion: Diabetes mellitus, whose prevalence is steadily increasing, is not yet well known in our population.

Техника выполнения атипичных ампутаций на стопе у больных с осложнённым течением синдрома диабетической стопы

Abstract. Introduction. Diabetes mellitus is one of the most common and socially important diseases in the world. The diabetic foot syndrome is one of the most complex diseases with a view to pathogenesis and one of the most serious complications of diabetes mellitus. This syndrome is characterized by disorders and changes of all structures of lower extremities, causes the ulcerous and necrotic processes. At the current moment, a traditional method in treatment of complications of the diabetic foot syndrome is amputation of lower extremities. Due to the large number of postoperative complications, the most preferable are economic amputations at the level of foot step. In modern conditions in the first stage of complex treatment of patients with purulent-necrotic process in the lower extremities, the recovery of main arterial blood circulation of the lower extremities in the form of open or endovascular angioplasty is effective. The most effective method is revascularization performed according to angiosomes areas of blood flow in footstep.
 
 Purpose of this study is to carry out a comparative assessment of the effectiveness of typical and atypical amputations at the level of footstep in patients with the most complicated course of the diabetic foot syndrome.
 
 Material. The objects of this study were patients with diabetes mellitus (DM) type 2 with purulent-necrotic complications of diabetic foot, treated at the surgical department department of the National N.I. Pirogov Surgical and Medical Center of the Saint- Petersburg of the SPb Clinical centre for the period 2010-2013. The main group included 68 patients. These patients were performed atypical interventions according to angiosomes blood flow to the tissues of the foot.
 
 Operative interventions at the level of footstep were carried out to 47 patients of the control group.
 
 Methods. An objective study to assess the local status, laboratory tests (clinical blood test, basic coagulogram, carbohydrate metabolism indexes) and duplex ultrasound study (USDI) of vessels of lower extremities were carried out. Obligatory angiography was performed in all patients. Surgical intervention in the form of dissection, drainage of purulent focus was carried out on an emergency basis prior to angiography only in patients with acute purulent processes in the lower extremities. In all other cases, the individual peculiarities of blood circulation disorder in lower extremities determined the choice of tactics of operative treatment. In 76% and 46% accordingly for each group after angiography, a balloon angioplasty was carried out for reconstruction of the main blood flow.
 
 Results and discussion. The average duration of the in-patient treatment in study group was 14,4±2,3. In the control group - 18,2±3,1. Duration of hospitalization differed significantly (p<0.05), but significant group of patients (31 and 18, respectively) were re-hospitalized during the period from 2 to 6 weeks after discharge from the hospital for the purpose of autodermoplasty for closure of surgical wounds.
 
 There were no significant differences between the postoperative healing time of wounds and wound surfaces after reconstructive interventions. This indicates the correct choice and method of operation, as well as indications for secondary wound closure.
 
 The authors note the difference in number of re-operations for recurrent purulent-necrotic process (2 patients in the study group and 9 patients in the control group). Re-operation was considered in the case of a destructive process to heal the original wound. Relapse necrotic phenomena was the main cause of the increase in terms of the impossibility of independent movement and 6.3±1,2 and 13.1±3.4 days, respectively (p<0.05). The authors explain these results by the fact that the leading role belongs to the qualitative blood circulation of paravulnar tissues in the postoperative wound healing in patients with diabetic foot syndrome.
 
 Conclusions.
 
 1. Preoperative angiography is prescribed to patients with purulent-necrotic complications of diabetic foot syndrome. If required, angioplasty before performing surgery on the tissues of the feet.
 
 2. The application of the principle angiosomes blood flow on the basis of the duplex ultrasound study (USDI) of arteries and angiography allows to choose the most rational tactics of surgical treatment.
 
 3. The use of atypical technique of amputations in the foot after preoperative examination can reduce the number of postoperative complications and the duration of inpatient treatment, to improve postoperative mobility and difficulty walking patients.

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A Study to evaluate Clinico-pathology and management of diabetic foot

Objective: The aim of the study bacteriology in diabetic wound, the pathophysiology of diabetic wound, various wound salvage procedures and outcome of different treatment modalities and newer techniques wherever applicable to prevent complications and to minimise the progression of occurred complication. Methods: The 100 patients admitted with diabetic foot in the department of Surgery, SBKS MIRC, Pipariya Vadodara (Gujrat) prospectively studied from July 2014 to Jan 2015. Patients with diabetes mellitus presenting with wound i.e. ulcer, blister, abscess, gangrene were included in our study. Patients with chronic wound due to cause other than diabetes such as traumatic, arterial, venous, trophic, TB, Syphilitic, malignant ulcer were excluded from study. Results: Highest number of cases was found in 51 – 60 years of age (34%) followed by 61 – 70 years of age (26%). 78 (78%) cases were male and 22 (22%) cases were female. Most of case had history of trauma 62%. As per Wegner’s classification of the diabetic foot 44 cases presented with grade 2 lesion, 32 cases grade 4 lesion, 18 cases grade 3 lesion, 4 cases grade 1 lesion, 2 cases, grade 5 lesion. Most of lesion (50%) are found in lower limb in which 40 cases presented with ulcer, 28 cases with gangrene of toe or limb, 16 cases with cellulitis, 4 cases with abscess and 12 cases with osteomyelitis. Most common isolated organism was s. aureus (36) followed by pseudomonas (20). The average hospitalisation in graded 2,3,4,5 lesion around 32 days .About 10% case required amputation while 56% cases managed only by daily dressing & slough excision. Among the complicated diabetic foot 12 patients developed osteomyelitis. All these patients had lesion of grade 3 and out of these 12 patients, 2 patients required AKA, 8 patients BKA, 5 patients had disarticulation from metatarsophalangeal joint. Conclusion : Diabetes affects all age groups, mainly manifest in middle part of life. Males are more affected than females. Neuropathy, ischemia along with immunological disturbance is important predisposing factor in pathophysiology. However both aerobic & anaerobic pathogens involve in diabetic wound infection but among them aerobic (mostly s. aureus ) is more common. Commonest presenting lesions in foot were ulcer, followed by cellulitis and gangrene. In the management of DFU the first requirement is strict control of diabetes, & early detection and treatment of lesions and regular foot care is also important.

Circulating endothelial progenitor cells and angiogenic factors in diabetes complicated diabetic foot and without foot complications

IntroductionData about angiogenic factors in diabetic foot syndrome (DFS) are insufficient. Therefore, in the present study we focus on circulating endothelial progenitor cells (EPCs) and two major angiogenic factors: vascular endothelial growth factor (VEGF-A) and fibroblast growth factor (FGF-2) in patients with DFS. Materials and methodsWe included 75 subjects: 45 patients with type 2 diabetes and 30 controls. The study group was divided into 2 subgroups: 23 patients with diabetic foot and 22 patients without diabetic complications. The concentration of VEGF-A, soluble VEGF receptor 2 (sVEGF-R2) and FGF-2 were measured in plasma samples. The number of circulating EPCs was determined in peripheral venous blood. The number of endothelial progenitor cells was measured with FACSCalibur flow cytometer using monoclonal antibodies directed against antigens specific for EPCs. ResultsIn our study we observed significant higher levels of VEGF-A and FGF-2 and lower sVEGF-R2 concentration in patients with T2DM compared to healthy subjects. The conducted analysis showed decreased levels of VEGF-A and elevated levels of FGF-2 in patients with DM complicated DFS compared to diabetic patients without DFS. Increased circulating EPCs number was reported in patients with DFS, and the difference was almost statistically significant. ConclusionsThe high concentration of VEGF-A and FGF-2, and a positive correlation between them indicate their participation in the process of angiogenesis in T2DM. Decreased sVEGF-R2 may result from inactivation of VEGF-A during complexes formation.

Overview on diabetic foot: a dangerous, but still orphan, disease

Diabetic foot disease is a major health problem that concerns 15% of the 200 million patients with diabetes worldwide. More than 60% of non-traumatic amputations in the western world are performed in the diabetic population. Many patients who undergo an amputation have a history of ulceration. Treatment of foot complications is one of the main items of consumption of economic and health resources in diabetic patients. Over recent years, knowledge about the physiopathological pathways of this complication has increased significantly, together with improvements in diagnostic techniques and, above all, the establishment of a standardized conservative therapeutic approach, which allows limb salvage in a high percentage of cases. An important prelude to diabetic foot treatment is the differential diagnosis between neuropathic and neuroischaemic foot, which is essential for effective treatment. Ulceration in neuropathic foot is due to biomechanical stress and high pressure, which involves the plantar surface of the toes and metatarsal heads. In the diabetic population, peripheral vascular disease (PVD) is the main risk factor for amputation. In diabetic patients, PVD is mostly distal, but often fully involves the femoral, popliteal, and tibial vessels. It can be successfully treated with either open surgical or endovascular procedures. If PVD is ignored, surgical treatment of the lesion cannot be successful. Infection is a serious complication of diabetic foot, especially when neuroischaemic: phlegmon and necrotizing fascitis are not only limb-threatening problems, but also life-threatening. In this case, emergency surgery is needed. The aim of this review is to describe the therapeutic strategies for the various types of diabetic foot syndrome.

Magnetic resonance imaging of diabetic foot complications.

This pictorial review aims to illustrate the various manifestations of the diabetic foot on magnetic resonance (MR) imaging. The utility of MR imaging and its imaging features in the diagnosis of pedal osteomyelitis are illustrated. There is often difficulty encountered in distinguishing osteomyelitis from neuroarthropathy, both clinically and on imaging. By providing an accurate diagnosis based on imaging, the radiologist plays a significant role in the management of patients with complications of diabetic foot.

Identifying type 2 diabetes risk classification systems and recommendations for review of podiatric care in an Australian Aboriginal health clinic.

BackgroundThere are several risk classification systems developed to facilitate diabetic foot assessments and prioritise diabetes patients for foot prevention services according to risk factors. Utilisation of both The University of Texas Diabetic Foot Risk Classification System (UTDFRCS) and The National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes (Part of the Guidelines on Management of Type 2 Diabetes), allows guidance for the podiatrist in terms of review timeframes for future assessments and treatment. The aim of this clinical audit was to classify Aboriginal type 2 diabetes subjects’ risk status according to UTDFRCS and identify if evidence based standards are being met for podiatry services at the Albury-Wodonga Aboriginal Health Service in New South Wales, Australia.MethodsA retrospective clinical audit over a twenty six month period was undertaken at the Albury-Wodonga Aboriginal Health Service, New South Wales. This is a primary health care facility that started podiatry services in August 2011. The primary variables of interest were the UTDFRCS for each subject and whether those participants met or did not meet the National Evidence-Based Guideline for review appointment timeframes. Other variables of interest include age, gender, duration of diabetes, occasions of visits and cancelled and failure to attend appointments to the podiatry service over the data collection period.ResultsThere was excellent overall adherence (94 %) of this sample population (n = 729) to the National Evidence-Based Guideline for podiatric review timeframes according to their risk status. Males were reported to be less likely to comply with the review timeframes compared to women. There was no association between risk status and age (OR = 1.04, p = 0.11), duration of diabetes (OR = 1.03, p = 0.71) or gender (OR = 0.77, p = 0.67).ConclusionsRegular foot examinations aid in stratifying patients according to risk status, guiding podiatry interventions to reduce the likelihood of ulceration and amputation. This primary health care setting has achieved podiatric evidence based standards for Aboriginal people with type 2 diabetes, demonstrated by acceptable timeframes for review appointments.

Predictive Role of Preventive Measures in Preventing the Progression of Diabetic Foot.

Introduction:Diabetes mellitus (DM) is one of the most common endocrine disease of modern life. Diabetic foot (DF) is the term for a foot of a patient suffering from DM with the potential risk of a number of pathological sequels, including infection, ulceration and/or destruction of deep tissue.Goal:To determine the importance of preventive measures to prevent the development of diabetic foot.Results:The gender structure of respondents categorized by the complication of DF (yes/no) was uniform. The average age was 60.15±12.2 years. Respondents without DF, 63% had 2 visits to the doctor a month, while in the group of those with DF, 39% of them had 3 visits to a doctor and 33% four or more times. Wearing comfortable shoes and foot hygiene in relation to the development of the DF are interdependent: c2=4,409; c2 = 12.47 (p <0.0005). Also, recurrent foot injury, and slow healing of sores in comparison to the development of the DF are mutually dependent; c2=13,195; c2=14 (p <0.0005).Conclusion:We found that there is a significant statistical relationship between preventive measures and development of the DF.

18-F flourodeoxy glucose positron emission tomography-computed tomography imaging: A viable alternative to three phase bone scan in evaluating diabetic foot complications?

Background:This paper is based on the initial findings from a prospective ongoing study to evaluate the efficacy of flourodeoxy glucose positron emission tomography-computed tomography (FDG-PET CT) in diabetic foot evaluation.Objective:The aim was to compare the diagnostic accuracies of three phase bone scan (TPBS) and FDG PET-CT (FDG-PET) in diabetic foot evaluation.Methods:Seventy-nine patients with complicated diabetic foot (osteomyelitis/cellulitis, Charcot's neuropathy) were prospectively investigated. TPBS (15 mci methylene di phosphonate [MDP] intravenous [IV]), followed by FDG-PET (5 mci IV) within 5 days were performed in all patients. Based on referral indication, patients grouped into Group I, n = 36, (?osteomyelitis/cellulitis) and Group II, n = 43 (?Charcot's neuropathy). Interpretation was based on intensity, extent, pattern of MDP and FDG uptake (standardized uptake value) along with CT correlation. Findings were compared with final diagnostic outcome based on bone/soft tissue culture in Group I and clinical, radiological or scintigraphic followup in Group II. Results: Group I: For diagnosing osteomyelitis, TP: TN: FP: FN were 14:5:2:2 by FDG PET and 13:02:05:03 by TPBS respectively. Sensitivity, specificity, positive predictive value and negative predictive value (NPV) of FDG-PET were 87.5%, 71%, 87.5% and 71% and 81.25%, 28.5%, 72% and 40% for TPBS, respectively. Group II: charcot's: cellulitis: Normal were 22:14:7 by FDG PET and 32:5:6 by TPBS, respectively.Conclusion:Flourodeoxy glucose PET-CT has a higher specificity and NPV than TPBS in diagnosing pedal osteomyelitis. TPBS, being highly sensitive is more useful than FDG-PET in detecting Charcot's neuropathy.

The Bacterial Characteristic of the Purulonecrotic Focus in Complicated Diabetic Foot Syndrome Depending on its Clinical Form

A study of the microflora of 1037 patients with complicated diabetic foot syndrome (DFS) was conducted over the period of 2010 through 2014. The quantity of gram-positive flora among aerobic germs increased from 52.7% (2010) to 61.4% (2014) with Staphylococcus aureus (62.5%) and Enterococcus faecalis (23.5%) prevailing. Enterobacter spp. and Escherichia coli prevailed among aerobic gram-negative flora. The plating of Pseudomonas aeruginosa grew from 17.2% (2010) to 22.4% (2014). The number of microbe associations extracted from the primary suppurative focus increased from 46.9% to 53.1%. Both common features and differences were discovered during the study of the microbial landscape of patients with different forms of complicated DFS. The increase in the dynamics of gram-positive flora study and the number of microbe associations, as well as the growth of MRSA, was a common pattern. The results of the antibiogram study are indicative of the high resistance of the detected microflora to I-II generation antibiotics.

Preventing foot complications in diabetes – The St Vincent Declaration 25 years on

Introduction In 1989 representatives of government health departments and patients' organisations from all European countries met diabetes experts in the Italian village of St Vincent and agreed a number of recommendations for member states to adhere to in order to improve diabetes care for their citizens. The target set for feet was to reduce the numbers of limb amputations for diabetic gangrene by 50% in a five year period.1 The ambitious targets were intended to kick-start governments and healthcare services into action. Equity of access and strong partnerships in care for people with diabetes was another target. It speaks volumes about the failure to meet the St Vincent target that this journal carries an article announcing the second campaign in two years on the subject of diabetic foot care.

Successful Treatment of a Patient With Complicated Diabetic Foot Wound: A Case Report.

Foot ulceration is one of the most serious complications of diabetes mellitus and may lead to amputation of the lower extremity. Timely prophylaxis and treatment of diabetic foot ulceration are important to maintain a good quality of life. This article reports a complicated diabetic patient with severe limb-threatening necrotizing infection. We successfully applied endovascular stent insertion, digit amputation, negative pressure wound therapy, and advanced dressings in different wound phases to achieve definitive wound healing after 12 months of treatment. Based on this case report, we would like to emphasize the importance of combined multiple therapies and patient compliance for severe diabetic foot ulcers.

Antimicrobial therapy in infectious complications of diabetic foot

Abstract Background and aims: The treatment of diabetic foot complications is combined, surgical and medical. The aim of our study was to assess the results of antimicrobial therapy in diabetic foot infections. Material and methods: 100 patients with diabetic foot infections admitted in the Surgery Clinic “I. Juvara” between December 2010 and February 2011 were analyzed. Results: Mean age at presentation was 58.4±9.74 years for women and 63.2±10.53 years for men. Mean diabetes duration was 12.3 years in men and 15.7 years in women. Patients with peripheral arterial disease represented 45% of cases, patients with neuropathy represented 16% of cases and patients with both conditions 39% of the cases. 41 patients suffered minor surgical interventions, 36 patients experienced minor amputations and 23 major amputations (below or above the knee). Antibiotic treatment included cephalosporins, fluoroquinolones and combinations with Metronidazole. After treatment, 74% of patients had a good postoperative evolution. For 26 patients a change of the antibiotic was necessary but only in 10 cases this was made according to antibiogram. Conclusions: Surgical debridement and wound management, carefully chosen antimicrobial therapy and treatment of comorbidities are very important for a successful outcome. Initial empirical antibiotic selection should be followed by culture-guided definitive therapy.

Ulcer piercing: Cleansing of complicated diabetic neuropathic foot ulcers by positive pressure irrigation

To demonstrate the efficacy of the ulcer piercing procedure, which allows constant cleansing of the ulcer and facilitates a positive pressure irrigation of any pierced hidden tracts, in order to reduce the negative impact of stasis on wound healing. We designed a surgical procedure of ulcer piercing and drainage with a silastic tube, which allows positive pressure irrigation of any pierced tracts. This procedure was performed in a continuous series of 25 selected diabetic patients affected by a Wagner stage 3 ulcer of the toe (n=16), metatarsal midfoot (n=5) and plantar Charcot foot (n=4), and with adequate foot arterial blood supply. Within 6 months of the ulcer piercing procedure, 23/25 of ulcers had completely healed. In two further cases, the ulcer piercing ring was still in place after 3 and 5 months, progressively healing with no active signs of infection. Taking into consideration the advantages and the lack of side effects afforded by this procedure, ulcer piercing represents a small but effective step towards an easier and safer approach to treating complicated diabetic neuropathic foot ulcers with adequate arterial blood supply. There were no external sources of funding for this study. The author has no conflicts of interest to declare with regard to the manuscript or its content.

Diabetic foot wounds: the value of negative pressure wound therapy with instillation

AbstractChronic wounds such as diabetic foot wounds are a tremendous burden to the health care system and often require a multidisciplinary approach to prevent amputations. Advanced technologies such as negative pressure wound therapy (NPWT) and bioengineered tissues have been successfully used in the treatment of these types of complex wounds. However, the introduction of NPWT with instillation (NPWTi) has provided an alternative treatment for treating complex and difficult‐to‐heal wounds. This article provides an overview of NPWT and the new NPWTi system and describes preliminary experience using NPWTi on patients with complicated infected diabetic foot wounds after surgical debridement and in a multidisciplinary setting.

The Charcot Foot

Charcot joint is an uncommon but often missed complication of the neuropathic diabetic foot. Prompt recognition and treatment with plantar pressure redistribution can prevent unnecessary amputation.

Differences in distribution and antimicrobial susceptibility of anaerobes isolated from complicated intra-abdominal infections versus diabetic foot infections

Few labs isolate and perform susceptibility tests on anaerobes; therefore, we studied the differences between 1185 anaerobes isolated from complicated intra-abdominal infections and 470 isolated from moderate to severe diabetic foot infections. They differed markedly in the distribution of species, including Bacteroides fragilis and anaerobic Gram-positive cocci, as well as in resistance patterns, especially to fluoroquinolones.

Характеристика микроциркуляции нижних конечностей у пациентов с осложненным синдромом диабетической стопы

Характеристика микроциркуляции нижних конечностей у пациентов с осложненным синдромом диабетической стопы

Critical Limb Ischemia in Association with Charcot Neuroarthropathy: Complex Endovascular Therapy for Limb Salvage

Charcot neuroarthropathy is a low-incidence complication of diabetic foot and is associated with ankle and hind foot deformity. Patients who have not developed deep ulcers are managed with offloading and supportive bracing or orthopedic arthrodesis. In patients who have developed ulcers and severe ankle instability and deformity, below-the-knee amputation is often indicated, especially when deformity and cutaneous involvement result in osteomyelitis. Ischemic association has not been described but can be present as a part of peripheral arterial disease in the diabetic population. In this extreme and advanced stage of combined neuroischemic diabetic foot disease, revascularization strategies can support surgical and orthopedic therapy, thus preventing osteomyelitis and leading to limb and foot salvage.