Risk Factors For Amputation Research Articles

Orthoplastic Classification Systems

Over the last few decades, there have been many important advances in the treatment of severe lower limb injuries. This article looks at a few of the more widely used classification systems and Injury Severity Scores to examine their utility in a practical setting. Gustilo and Anderson formulated their landmark classification system in 1976 (J Bone Joint Surg Am. 1976;58:453-458). For the Gustilo classification system to serve any useful purpose, it is necessary to include supplemental information, whenever discussing these injuries, that includes the mechanism and energy of the injury and the presence of any other concomitant injuries or comorbidities. Byrd et al (Plast Reconstr Surg. 1985;76:719-728) recognized some of the shortcomings of the Gustilo-Anderson system and proposed a classification system of their own in 1985. The Byrd-Spicer classification is less commonly used, mainly because of a large degree of interobserver variability, but it includes energy and presence of devitalized tissue. The Predictive Salvage Index, devised in 1987, recognized the importance of vascular injury as a prognostic indicator and was formulated in an attempt to avoid not only unnecessary amputations, but also to avoid protracted attempts at salvage that might eventually be converted into a delayed amputation. The Mangled Extremity Severity Score looked at 4 variables: patient age; the presence and duration of shock; ischemia time; and the energy of the injury. Critics question the relevance of its parameters. The 7 components of the Limb Salvage Index include injury to an artery, deep vein, nerve, bone, skin, and muscle as well as warm ischemia time. However, predictive results have not been reproduced. The Hanover Fracture Scale was initially developed on the basis of 13 weighted variables to quantify risk factors for amputation and complications in high-energy trauma to a limb. This included index bacteriology, and was weighted heavily toward the presence of vascular injury. Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score attempted to address criticized weaknesses of the Mangled Extremity Severity Score. These scores can be useful tools in the decision-making process when used cautiously, but should not be used as the principal means for reaching difficult decisions.

Management of patients hospitalized for diabetic foot infection: Results of the French OPIDIA study

Aim This study was an analysis of how diabetic patients with infected foot wounds are managed in hospital by departments specializing in diabetic foot pathology, including an evaluation of the outcome 1 year after discharge. Methods This was a prospective study of a cohort of patients hospitalized for diabetic foot infection at 38 hospital centres in France and followed-up for 1 year after discharge. Results Altogether, 291 patients were included (73% male; 85% type 2 diabetes; mean age: 64.3 ± 11.7 years). Most of the wounds were located on the toes and forefoot, and infection was most often graded as moderate; nevertheless, in about 50% of patients, osteomyelitis was suspected. Also, 87% of patients had peripheral neuropathy and 50–62% had peripheral artery disease. Gram-positive cocci, and Staphylococcus aureus in particular, were by far the most frequently isolated microorganisms. During hospitalization, lower-limb amputation was performed in 35% of patients; in 52%, the wound healed or had a favourable outcome. A year after discharge, 150 non-amputated patients were examined: at this time, 19% had to undergo amputation, whereas 79% had healed their wounds with no relapse. Risk factors for amputation were location (toes), severity of the wound and presence of osteomyelitis. Peripheral artery disease was associated with a poor prognosis, yet was very often neglected. Conclusion In spite of being managed at specialized centres that were, in general, following the agreed-upon published guidelines, the prognosis for diabetic foot infection remains poor, with a high rate (48%) of lower-limb amputation.

Advances in treatment of diabetic foot ulcers

Diabetic foot is a major health problem all over the world. Approximately 15% of the 200 million people with diabetes worldwide will develop a foot ulcer during their lifetime. Major amputation is a feared complication of diabetes. Many patients who undergo an amputation have a history of ulceration. More than 60% of non-traumatic amputations in the western world are carried out in diabetes patients. Major amputations increase morbidity and mortality and reduce the patient's quality of life. An important prelude to diabetic foot treatment is the differing diagnosis of neuropathic and neuroischemic foot. Treatment of a neuropathic plantar ulcer must correct pathological plantar distribution of pressures. Surgical treatment of deformities, with or without ulcerations, is an effective therapy. Charcot neuroarthropathy is a particular complication of neuropathy wich may lead to fragmentation or destruction of joints and bones. Additionally, in the diabetic population peripheral vascular disease (PVD) is the main risk factor for amputation. If PVD is not diagnosed, treatment of the ulcer cannot be successful. In diabetic patients PVD is distal, but often fully involves the femoral, popliteal and tibial vessels. It can be successfully treated with either open surgical or endovascular procedures. Finally, infection is a serious complication of diabetic foot. Phlegmon or necrotizing fascitis are not only limb-threatening problems, but also life-threatening ones. In this case emergency surgery is mandatory.

Medical Therapy of Diabetic Foot Infections

Diabetic foot infections are a common and often serious problem, accounting for more hospital bed days than any other complication of diabetes. Despite advances in antibiotic drug therapy and surgical management, these infections continue to be a major risk factor for amputations of the lower extremity. Although a variety of wound size and depth classification systems have been adapted for use in codifying diabetic foot ulcerations, none are specific to infection. In 2003, the International Working Group on the Diabetic Foot developed guidelines for managing diabetic foot infections, including the first severity scale specific to these infections. The following year, the Infectious Diseases Society of America published their diabetic foot infection guidelines. Herein, we review some of the critical points from the Executive Summary of the Infectious Diseases Society of America document and provide a commentary following each issue to update the reader on any pertinent changes that have occurred since publication of the original document in 2004. The importance of a multidisciplinary limb salvage team, apropos of this special issue jointly published by the American Podiatric Medical Association and the Society for Vascular Surgery, cannot be overstated.

Medical therapy of diabetic foot infections

Diabetic foot infections are a common and often serious problem, accounting for a greater number of hospital bed days than any other complication of diabetes. Despite advances in both antibiotic therapy and surgical management, these infections continue to be a major risk factor for amputations of the lower extremity. Although a number of wound size and depth classification systems have been adapted for use in codifying diabetic foot ulcerations, none are specific for infection. In 2003, the International Working Group on the Diabetic Foot developed guidelines for managing diabetic foot infections, including the first severity scale specific for these infections. The following year, the Infectious Diseases Society of America (IDSA) published their Diabetic Foot Infection Guidelines. In this article, we review some of the critical points from the Executive Summary of the IDSA document and provide a commentary following each issue to update the reader on any pertinent changes that have occurred since the publication of the original document in 2004. The importance of a multidisciplinary limb salvage team, apropos this special joint issue of the American Podiatric Medical Association and the Society for Vascular Surgery, cannot be overstated.

Analysis of amputation risk factors in 436 patients with diabetic foot ulcers

Objective To investigate the risk factors related to amputation in the patients with diabetic foot ulcer.Methods Four-hundred and thirty-six diabetic patients with foot ulcer were retrospectively investigated regarding their demographic data,diabetes and related diseases treatment,severity and size of foot deers,with and without infection,and blood biochemistry parameters.The patients were divided into two groups:i.e.with and without amputation.Results Ninety-seven patients(22.2%)underwent amputation.No significant statistic differences in age,sex,blood glucose level,and foot ulcer duration were found between two groups.Higher prevalence of peripheml vascular disease(94.8% vs 86.1%,P<0.05),higher white blood cell counts[(10.80±6.03 vs 8.09±3.59)×10~9/L,P<0.01],and raised high sensitivity C-reactive protein levelI(10.2±6.2 vs 6.9±6.1)retool/L.P<0.01] and lower plasma albumin[(35.0±5.1 vs 36.8±5.0)g/L,P<0.01],blood hemoglobin[(104.3±18.9 vs 114.1±21.0)g/L.JP<0.01],serum total cholesteroll(4.2±0.9 vs 4.7±1.3)mmool/L,P<0.01],triglycerides[(1.2±0.5 vs 1.6±1.3)mmol/L,P<0.01],high-density lipoprotein-cholesterol[(1.1±0.5 vs 1.2±0.3)mmol/L.P<0.01],and low-density lipoprotein.cholesterol[(2.7±0.8 vs 3.0±1.0)mmool/L,P<0.05]levels were found in amputation group compared with the non-amputation group.Multiple logistic regression showed that peripheral vascular disease.white blood cells,cholesterol,and high sensitivity C.reactive protein were the independent risk factors of amputation.Conclusions The severity of diabetic foot ulcer,peripheral artery disease,inflammation factors,and malnutrition are important factors leading to amputation due to the unhealed ulcers. Key words: Diabetic foot; Amputation; Risk factors

Outcome Predictors in Traumatic Popliteal Artery Injury

Background: In the last century, significantly reduced amputation rates in patients with traumatic popliteal artery injury have been achieved with improved revascularization techniques; however, failed revascularization remains a vexing problem for clinicians and has a devastating outcome for patients. We reviewed our experience with popliteal artery injuries at a civilian level I trauma center. The objective of the current study was to document the mechanism of popliteal artery injury, methods of repair, and to determine risk factors for amputation. Methods: From January 2002 to June 2009, 68 patients with popliteal artery injuries were identified in the trauma registry. We conducted a retrospective record review documenting age, mechanism of injury, associated orthopedic injury, venous injury, use of fasciotomy, mangled extremity severity score (MESS), and injury severity score (ISS). Univariate and multivariate analysis was performed to determine risk factors for amputation. Results: We identified 70 popliteal artery injuries in 68 patients. Median age was 33 years (range, 5-88 years), and 57 patients (81%) were male. Blunt trauma was the cause of 51 injuries (73%). Associated venous injuries were present in 16 (23%). Associated orthopedic injuries included 19 dislocations (27%) and 49 fractures (70%). The median MESS was 5 (range, 2-9) and the median ISS was 9 (range, 4-41). Fifteen patients (21%) required amputation: 8 primary (11%) and 7 secondary (10%). Revascularization was performed in 62 cases (89%). Compartment syndrome was documented in 23% of patients, and 56% underwent fasciotomy. Univariate analysis was calculated for each predictor variable. Four variables were significantly associated with amputation: MESS (odds ratio [OR], 2.44; P < .0001); ISS >10 vs ISS <9 (OR, 7.41; P < .0429); blunt injury (OR, 10.69; P = .0088), and fractures (OR, 0.13; P < .0437). By multiple exact logistic regression, MESS (P < .05) was the only significant predictor of amputation. The increased odds of amputation were similar for primary (OR, 2.60; P = .001) and secondary (OR, 2.39; P = .002) amputations. Conclusion: Patients with traumatic popliteal artery injury are at high risk for amputation. Blunt injury, associated fractures, MESS, and ISS >9 were significantly associated with amputation. MESS was a significant predictor of amputation and should be considered if revascularization is planned in these critically injured patients.

Poster 237: Risk Factors for Amputations in Patients with Spina Bifida

Poster 237: Risk Factors for Amputations in Patients with Spina Bifida

Amputation rate in 147 Turkish patients with diabetic foot: the Hacettepe University Hospital experience.

To determine the lower extremity amputation rate and the risk factors for amputation, we analysed the medical records of 147 Turkish diabetic patients who have been referred to the clinic with diabetic foot. Eleven patients (7.5%) had type 1, and 136 patients (92.5%) had type 2 diabetes mellitus. Fifty-four patients (36.7%) have undergone amputation due to diabetic foot. Femoropopliteal by-pass has been performed in 4 patients in the non-amputees group who did not have gangrene. None of the patients in the amputees group has undergone a revascularisation procedure. Considering all lower-extremity amputations in the group studied, 25.9% were transphalangial amputations, 3.7% were transmetatarsal amputations, 7.4% were Syme type amputations, 51.9% were below-knee amputations, and 11.1% were above-knee amputations. In a logistic regression model, age, gender, duration of diabetes, smoking history, hypertension, retinopathy, nephropathy, and peripheral neuropathy were insignificant factors in determining the risk of amputation. In contrast, presence of peripheral vascular disease (odds ratio 4.0, 95% CI 1.17-13.4; p = 0.03), osteomyelitis (odds ratio 3.73, 95% CI 1.08-12.6; p = 0.04) and gangrene (odds ratio 30.8, 95% CI 7.39-121.5; p < 0.0001) were found to be the significant predictors of amputation. The mortality rate due to amputation during hospital stay was 13.2%. These data suggest that lower extremity amputation is a frequently encountered outcome of the hospitalized patients in Turkish diabetic population with diabetic foot which mainly occur due to peripheral vascular disease, osteomyelitis and gangrene. Lack of adequate vascularisation procedures might have contributed to a high percentage of major amputations in the group studied. Population-based studies should be undertaken in order to determine the status of lower extremity amputation as a whole in Turkish diabetic population.

Popliteal Artery Aneurysm: Epidemiology and Modern Management

PAA is a predominantly male disease, more than 90% of affected patients are men. Riskfactors for amputation are poor run-off, use of a synthetic graft, emergency treatment and high age. The frequency of amputation decreased over time in Sweden, which was associated with increased use of preoperative thrombolysis and fasciotomy. Thrombolysis can transform an emergent into an elective situation, and often improves out-flow. The risk of late amputation is low. Operation with a Posterior approach is associated with lower risk of late expansion, and is considered first choice of treatment when a short by-pass is sufficient. Multiple aneurysm disease is common among patients with PAA, in particular among those with bilateral PAA. All patients, irrespective of age, should be included in a life-long surveillance program. Normal arterial segments should be re-examined after three years.

Surgical treatment of 154 patients with non-traumatic acute lower limb ischemia

To analyze the surgical treatment and prognosis of non-traumatic acute lower limb ischemia, and compare the morbidity and prognosis of acute arterial embolism and acute arterial thrombosis. The clinical data of 154 acute lower limb ischemia patients surgically treated from July 1999 to December 2007 were retrospectively analyzed. Fogarty catheter embolectomy was used in all patients; in which, 128 cases underwent Fogarty catheter embolectomy only, 8 cases Fogarty catheter embolectomy combined with endarterectomy, 13 cases Fogarty catheter embolectomy combined with vascular reconstruction with prosthetic graft or great saphenous vein, 5 cases Fogarty catheter embolectomy combined with amputation. The patients were divided into two groups according to pathogenesis: acute arterial embolism group (99 cases) and acute arterial thrombosis group (55 cases). The morbidity, amputation, perioperative mortality rates and high risk factors of amputation in the two groups were compared. Female experienced acute arterial embolism more often than man (60.6% vs 39.4%, P < 0.05), and more acute arterial thrombosis occurred in man (72.7% vs 27.3%, P < 0.05). The amputation rate of all cases was 9.7%, and perioperative mortality rate was 11.7%. The amputation rate in acute arterial embolism group was lower than acute arterial thrombosis group (5.1% vs 18.2%, P < 0.05). The perioperative mortality rates in the two groups were equal (11.1% vs 12.7%, P > 0.05). The statistically high risk factor of amputation for two groups was ischemic time, and smoking and diabetes were high risk factors for acute arterial thrombosis. Men experiences acute arterial thrombosis more often, and women experiences acute arterial embolism more often. The amputation rate of acute arterial embolism is lower than acute arterial thrombosis, and acute arterial thrombosis has more high risk factors of amputation.

Wound Bioburden and Infection-Related Complications in Diabetic Foot Ulcers

The identification and diagnosis of diabetic foot ulcer (DFU) infections remains a complex problem. Because inflammatory responses to microbial invasion may be diminished in persons with diabetes, clinical signs of infection are often absent in persons with DFUs when infection is limited to localized tissue. In the absence of these clinical signs, microbial load is believed to be the best indicator of infection. Some researchers, however, believe microbial load to be insignificant and type of organism growing in the ulcer to be most important. Previous studies on the microbiology of DFUs have not provided enough evidence to determine the microbiological parameters of importance.Infection-related complications of DFUs include wound deterioration, osteomyelitis, and amputation. Risk factors for amputation include age, peripheral vascular disease, low transcutaneous oxygen, smoking, and poor glycemic control. These risk factors are best measured directly with physiological measures of arterial perfusion, glycemic control, sensory neuropathy, plantar pressures, and activity level and by controlling off-loading. DFU bioburden has not been examined as a risk factor for infection-related complications. To address the relationship between wound bioburden and the development of infection-related complications in DFUs, tightly controlled prospective studies based on clearly defined, valid measures of wound bioburden and wound outcomes are needed. This article reviews the literature and proposes a model of hypothesized relationships between wound bioburden-including microbial load, microbial diversity, and pathogenicity of organisms-and the development of infection-related complications.

Outcome After Leg Bypass Surgery for Critical Limb Ischemia Is Poor in Patients With Diabetes

Our aim was to assess the risk of major amputation or death after leg bypass surgery for critical limb ischemia in patients with diabetes versus those without. We did a population-based cohort study by linking nationwide databases in Sweden. We identified 1,840 patients in the Swedish Vascular Registry who had their first leg bypass procedure for critical lower-limb ischemia between 1 January 2001 and 31 December 2003-742 with and 1,098 without diabetes. Our primary end point was first major amputation of the limb on which bypass was done or death. Individuals were followed up until 31 December 2005 through the National Hospital Patient Registry and the Cause-of-Death Registry. Incidence of ipsilateral amputation or death was higher in patients with diabetes than in patients without (30.2 vs. 22 events/100 person-years; crude hazard ratio [HR] 1.32 [95% CI 1.17-1.50]). Similarly, individuals with diabetes had a shorter amputation-free survival period than individuals without (2.3 years, range 1.9-2.8 vs. 3.4 years, range 3.1-3.7). Adjustment for demographic characteristics, comorbidities, and risk factors for amputation or death did not substantially affect the risk (HR 1.46 [95% CI 1.26-1.69]). The effect was more pronounced in male (1.75 [1.47-2.08]) than in female (1.35 [1.11-1.64]) patients after adjustment for age. Diabetes is associated with lower amputation-free survival after leg bypass for critical limb ischemia. Patients with diabetes and limb ischemia need intensified treatment of diabetes-related risk factors to improve outcome.

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.

Mid-term results with laser atherectomy in the treatment of infrainguinal occlusive disease

Laser atherectomy offers a potential intervention for multivessel infrainguinal disease in patients with poor revascularization options. Despite promising early results reported in the literature, the proper patient population who might benefit from laser atherectomy has yet to be determined. From July 2004 to June 2006, patients undergoing laser atherectomy were retrospectively reviewed and assessed for comorbidities, operative and follow-up variables potentially associated with the end points of nondefinitive therapy, and limb salvage. During the study period, 40 patients (21 women, 19 men) underwent laser atherectomy, and the average follow-up was 461 +/- 49 days (range, 17 to 1050 days). Their average age was 68 +/- 2 years (range, 43 to 93 years). The indication for laser atherectomy was critical limb ischemia in 26 (65%) and lower limb claudication in 11 (35%). A total of 47 lesions were treated in the following arterial segments: 34 femoropopliteal and 13 infrapopliteal. Femoropopliteal distribution by the Trans-Atlantic Society Classification (TASC) was A in 3, B in 17, C in 10, D in 4, and infrapopliteal lesions distribution was A in 1, B in 3, C in 4, and D in 5. Adjunctive angioplasty was used in 75% of cases. The overall technical success rate (<50% residual stenosis) was 88%. Laser atherectomy-based treatment was the definitive therapy for 23 patients (58%), and the overall 12-month primary patency was 44%. The limb salvage rate at 12 months in 26 patients with critical limb ischemia was 55%. Renal failure was a risk factor for amputation (P < .001) and failed primary patency (P < .05), type 2 diabetes mellitus was a risk factor for amputation (P < .05), and poor tibial runoff was associated with failed primary patency and amputation (P < .05). Outcome was associated with the number of patent infrapopliteal runoff vessels. These data demonstrate that laser atherectomy can be used with high initial technical success rate. Chronic renal failure and diabetes are risk factors for a negative outcome. Poor results in patients with diabetes and renal failure necessitate careful case selection in this subgroup, in which laser atherectomy is less likely to provide a definitive revascularization result or limb salvage.

Nationwide study of the outcome of popliteal artery aneurysms treated surgically

The aim was to study the epidemiology and outcomes of popliteal artery aneurysm (PA) treated surgically. Among 110,000 procedures registered prospectively in the Swedish Vascular Registry (Swedvasc), there were 717 primary operations for PA among 571 patients. Patient records were reviewed and data validated against other registries. The median age of the patients was 71 years; 5.8 per cent were women. Among 264 legs treated urgently, 235 had acute ischemia and 24 had rupture. Of patients with unilateral PA, 28.1 per cent had an aortic aneurysm, 8.4 per cent an iliac aneurysm and 9.4 per cent a femoral aneurysm. Extra-popliteal aneurysms were more common when the PAs were bilateral (P = 0.004). The rate of limb loss within 1 year of operation was 8.8 per cent; 12.0 per cent for symptomatic and 1.8 per cent for asymptomatic limbs (P < 0.001). Risk factors for amputation were symptomatic disease, poor run-off, urgent treatment, age over 70 years, prosthetic graft and no preoperative thrombolysis when the ischaemia was acute. Amputation rates decreased over time (P = 0.003). Crude survival was 91.4 per cent at 1 year and 70.0 per cent at 5 years. Multiple aneurysm disease was common when PAs were bilateral. Preoperative thrombolysis of acute thrombosis and the use of vein grafts for bypass improved outcome.

P1468 Predictive risk factors for amputation in diabetic fetid foot infections

The objective of this study was to characterise the β-lactamase genes of cephalosporin-resistant Escherichia coli isolated from farm animals in Guangdong Province of China. Of 592 E. coli isolates recovered from farm animals from 2003–2005, 50 (8.4%) showed cephalosporin resistance. Polymerase chain reaction and sequencing analysis showed that 14 isolates (2.4%) from chickens, ducks, pigs and partridges were positive for the blaCTX-M gene (10 for blaCTX-M-14 and 4 for blaCTX-M-27). CMY-2 was detected for the first time in mainland China in six E. coli isolates (1.0%) from chickens and goose. Except for one isolate, blaCTX-M- and blaCMY-2-containing isolates also harboured the blaTEM-1b gene. Conjugation experiments demonstrated that the blaCTX-M and blaTEM genes could be transferred to E. coli DH5α. Pulsed-field gel electrophoresis (PFGE) showed that the 14 CTX-M-producing isolates belonged to 12 different types. Two isolates (one from a chicken, the other from a pig) containing CTX-M-14 showed indistinguishable PFGE patterns, indicating clonal dissemination of this strain among animals from different farms. This study describes for the first time the emergence of CTX-M- and CMY-2-producing E. coli among farm animals in China, with the CTX-M-9 group being the predominant extended-spectrum β-lactamase detected.

Treatment of Diabetic Foot Ulcer: An Overview Strategies for Clinical Approach

Diabetic foot disease is a major health problem, which concerns 15% of the 200 million patients with diabetes worldwide. Major amputation, above or below the knee, is a feared complication of diabetes. 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. Major amputations increase morbility and mortality and reduce the patient's quality of life. Treatment of foot complications is one of the main items in the absorption of economic and health resources addressed to the diabetic population. It is clear that effective treatment can bring about a reduction in the number of major amputations. Over recent years, we have seen a significant increase in knowledge about the physiopathological pathways of this complication, together with improvements in diagnostic techniques, but above all a standardized conservative therapeutic approach, which allows limb salvage in a high percentage of cases. This target has been achieved in specialized centers. An important prelude to diabetic foot treatment is the differing diagnosis of neuropathic and neuroischemic foot. This differentiation is essential for effective treatment. Ulceration in neuropathic foot is due to biomechanical stress and high pressure, which involves the plantar surface of toes and metatarsal heads. Treatment of a neuropathic plantar ulcer must correct pathological plantar pressures through weight bearing relief. Surgical treatment of deformities, with or without ulcerations, is effective therapy. A neuropathic ulcer that is not adequately treated can become a chronic ulcer that does not heal. An ulcer that does not heal for many months has a high probability of leading to osteomyelitis, for which treatment with antibiotics is not useful and which usually requires a surgical procedure. Charcot neuroarthropathy is a particular complication of neuropathy which may lead to fragmentation or destruction of joints and bones. A well-timed diagnosis of Charcot neuroartropathy is essential to avoid deformities of chronic evolution. In the diabetic population peripheral vascular disease (PVD) is the main risk factor for amputation. If peripheral vascular disease is ignored, surgical treatment of the lesion cannot be successful. In diabetic patients, PVD is especially distal, but often fully involves the femoral, popliteal and tibial vessels. It can be successfully treated with either open surgical or endovascular procedures. Infection is a serious complication of diabetic foot, especially when neuroischemic: phlegmon or necrotizing fascitis are not only limb-threatening problems, but also life-threatening ones. In this case, emergency surgery is needed. Primary and secondary prevention of foot ulceration is the main target. Prevention programs must be carried out to highlight risk factors, lowering amputation incidence.

Changes in the management of critical limb ischaemia.

A prospective study of all patients with critical limb ischaemia (CLI) who presented to a single vascular unit was undertaken for a 12-month period. There were 222 referrals in 188 patients, 80.2 per cent of which were emergency or urgent admissions. The majority (72.5 per cent) were initially investigated with colour duplex scanning to characterize the arterial lesion. Diagnostic angiography was performed in 35.1 per cent. An attempt at revascularization was made in 73.0 per cent of cases using percutaneous transluminal angioplasty (PTA) in 42.3 per cent, surgery in 24.3 per cent, and a combination of surgery and PTA in 6.3 per cent. Primary major amputation was required in 22 cases (9.9 per cent) and conservative treatments were used in 38 (17.1 per cent). The in-hospital mortality rate was 10 per cent with a limb salvage rate of 79 per cent. Diabetes was an independent risk factor for amputation (odds ratio 2.4, 95 per cent confidence interval 1.22-4.79, P = 0.012). Median hospital stay was much shorter for patients treated by PTA (4.5 days) than surgery (16 days) or primary amputation (18 days). The complication rate of PTA requiring surgery was 5.5 per cent. CLI represents a large non-elective workload for a vascular unit. The increasing use of non-invasive duplex assessment and angioplasty plays a major part in the successful management of these patients.

Group B streptococcal soft tissue infections in non-pregnant adults

Skin and soft tissue infections are the most common presentations of invasive Streptococcus agalactiae infections. This study reviewed 71 patients in a medical centre in southern Taiwan with S. agalactiae soft tissue infections. The mortality rate was 7%, and 11% of patients lost their extremities following extensive tissue necrosis. Critical illness and the presence of cutaneous ulceration heralded a fatal prognosis. Risk-factors for amputation of limbs included advanced age, cutaneous ulceration and polymicrobial infection. It was concluded that invasive S. agalactiae soft tissue infections, as with infections caused by Streptococcus pyogenes, can also lead to substantial morbidity and mortality in non-pregnant adults.