Texas Grade Research Articles

Proximal Tibial Cortex Transverse Distraction Facilitating Healing and Limb Salvage in Severe and Recalcitrant Diabetic Foot Ulcers.

Proximal Tibial Cortex Transverse Distraction Facilitating Healing and Limb Salvage in Severe and Recalcitrant Diabetic Foot Ulcers.

Adjuvant antibiotic loaded bio composite in the management of diabetic foot osteomyelitis — A multicentre study

BackgroundDiabetic foot ulcers are associated with a high morbidity and are common cause of non-traumatic lower limb amputations. The effect of debridement and the use of an adjuvant local antibiotic carrier in the treatment of diabetic foot ulcers with osteomyelitis was evaluated. MethodsA retrospective review of patients with diabetic foot ulceration and osteomyelitis treated by debridement with adjuvant local antibiotic was performed. Seventy patients with Texas Grade 3B & 3D lesions were included, with a mean age of 68 years. Cerament G, an antibiotic-loaded absorbable calcium sulphate/hydroxyapatite bio-composite was used along with intraoperative multiple bone sampling and culture-specific systemic antibiotics. ResultsPatients were followed up until infection eradication or ulcer healing. Mean follow up was 10 months (4–28months). Nine patients had Charcot foot deformity, 14 had peripheral vascular disease. 62% of patients had forefoot, 5% midfoot and 33% hind foot involvement. Fifty-three patients (87%) had polymicrobial infection. Staphylococcus aureus was the most common microorganism isolated. Infection was eradicated in 63 patients (90%) with mean time to ulcer healing of 12 weeks. Seven patients were not cured and required further treatment. Five patients had below knee amputation. ConclusionsAdjuvant, local antibiotic therapy with an absorbable bio-composite can help achieve up to 90% cure rates in diabetic foot ulceration with osteomyelitis. Cerament G can act as effective void filler allowing dead space management after excision and preventing reinfection and the need for multiple surgical procedures. Level of evidenceLevel IV- case series.

Differentiated treatment of patients with diabetic foot syndrome at the stage of specialized surgical care

To assess 1-year results of differentiated treatment of patients with diabetic foot syndrome (DFS) who were included into 3-year register of diabetic foot outpatient practice (DFOP). It was performed retrospective analysis of 570 patients with DFS (2015-2017): group I - neuropathic form (n=285), group II - neuroischemic form (n=285). Patients were classified according to Texas grade. Group I - 107 (37.5%) patients (BI-III); 91 (31.9%) patients (AII+BII-III). Diabetic osteoarthropathy was diagnosed in 97 (34.0%) cases. Group II included 113 (45.2%) patients with DI-III and 171 (60.0%) patients with CII-II+DII-III. 308 patients received combined outpatient treatment (including limb off-loading in 88%), 195 patients - in-hospital surgical treatment (including endovascular procedures - 52), 67 patients - treatment at the place of residence. Postoperative follow-up was in diabetic foot outpatient practice. Statistical analysis of data was performed by using of Biostat software package. In group I 1-year results are unknown in 76 (26.7%) patients. Epitheliazation was noted in 101 (35.4%) cases, persistent diabetic ulcer - in 27 (12.9%), small amputations - 16 (7.7%), high amputations - 2 (0.95%). In group II results are unknown in 29 (10.2%) patients. Epitheliazation occurred in 121 (47.3%) cases, persistent diabetic ulcer - 53 (20.7%), small amputations - 47 (18.4%), high amputations - in 35 (13.7%) cases. DFOP is a key organizational unit of specialized medical care for patients with DFS. Regular follow-up of patients in DFOP and combined treatment at the stage of specialized surgical care allows to preserve limb in 99% of patients with neuropathic foot and in 86.3% of patients with neuroischemic foot.

Outpatient Negative-Pressure Wound Therapy Following Surgical Debridement: Results and Complications.

To present results and complications in a case series of outpatients with diabetic and neuropathic foot ulcers with exposed bone following surgical debridement treated with negative-pressure wound therapy (NPWT). Retrospective data were obtained from digital medical records from the Maccabi Health Services High Risk Foot Clinic in Tel Aviv, Israel, between 2009 and 2014. Medical records examined were those of clinic outpatients with exposed bone following partial foot amputation or selective bone debridement (University of Texas grade III-A) treated with NPWT. Wound area, closure rate, and adverse events. There were 66 patients provided NPWT in a total of 77 treatment courses. Mean patient age was 62 ± 10 years, 82% were male, and mean diabetes mellitus duration was 14 ± 8 years. Mean HbA1C levels were 8.1% ± 1.7%. Mean treatment course duration was 16 days (range, 2-42 days). Wound area decreased significantly (from 11.3 ± 16.8 cm to 8.0 ± 13.3 cm, P < .0001). Ulcer curing was noted in 7% of the cases, and healing progression was noted in 54%. Seven serious adverse events were recorded. Outpatient NPWT is a relatively safe and effective adjuvant to surgical debridement of neuropathic foot ulcers. In an outpatient setting, one can expect serious adverse events to occur in 10% of cases, but this seems unavoidable in patients with diabetic foot ulcers when taking into account their comorbidities and patient resources. Strict protocols to promote early recognition of complications and appropriate response to minimize deterioration must be implemented.

Mobility and Academic Achievement for Texas Grade 7 Students: A Multiyear Investigation

Mobility and Academic Achievement for Texas Grade 7 Students: A Multiyear Investigation

Effectiveness of Conventional and Herbal Treatment on Diabetic Foot Ulcer Using Texas and Wagner Wound Scales

In type2 diabetic mellitus(DM) complication can occur in the micro vascular and macro vascular blood vessels. Diabetic foot ulcer is one of the most complicated problem leads to gangrene and can extend to the level of amputation. The aim of this study is to compare the effectiveness of conventional and herbal treatment in diabetic foot ulcer. A total of 160 diabetic patients with foot ulcer were selected randomly and divided into conventional and herbal treatment groups(n=80 each). Wound measurement was done using Texas wound measurement scale and Wagner wound grading scale. In conventional treatment group and in herbal treatment group the stage and grade were assessed in pre-test and post test 1 after 15 days and post test 2 after 30 days. There are significant changes found in wound stage ischemia and infection(D), ischemia(C) infection present (B), and no infection or ischemia (A). The Texas scale stage χ2analysis showed significant difference.(p<0.023) This showed that the herbal treatment is better thanconventional treatment. In Texas grading system of the wound there is indication of improvement (marginally significant (p< 0.09) in the second visit and there is a highly significant change in the third visit after 30 days of post test. (p <0.001) The wagner grading system for diabetic foot infections, grading scale herbal treatment was better than conventional treatment but statistically not significant.(P=0.363)

Differences in the English Proficiency Levels of Texas Grade 3 English Language Learners as a Function of Bilingual Program

Differences in the English Proficiency Levels of Texas Grade 3 English Language Learners as a Function of Bilingual Program

Mini-Invasive floating metatarsal osteotomy for resistant or recurrent neuropathic plantar metatarsal head ulcers.

BackgroundPatients with peripheral neuropathy and pressure under a relatively plantar deviated metatarsal head frequently develop plantar foot ulcers. When conservative management with orthotics and shoes does not cure the ulcer, surgical metatarsal osteotomy may be indicated to relieve the pressure and enable the ulcer to heal. The purpose of this study is to evaluate the use of a mini-invasive floating metatarsal osteotomy in treating recalcitrant ulcers or recurrent ulcers plantar to the metatarsal heads in patients with diabetes mellitus (DM) related neuropathy.MethodsComputerized medical files of patients with diabetic neuropathy treated with an osteotomy during 2013 and 2014 were retrospectively reviewed. There were 20 osteotomies performed on 17 patients (mean age 58 years). The patients had a diagnosis of DM for a mean of 17 years. All ulcers were University of Texas grade 1A; mean ulcer age was 19 months.ResultsAfter 17/20 operations, the ulcer completely resolved after 6 weeks and did not recur after a mean follow-up of 11.5 months. One patient developed an early post-operative infection with osteomyelitis at the osteotomy site (proximal shaft of the fifth metatarsal) that needed debridement and IV antibiotics. In the other 19 cases, the surgical wound healed within 1 week. Asymptomatic radiological non-union developed in six cases (30 %).ConclusionsMini-invasive floating metatarsal osteotomy can cure resistant and recurrent University of Texas grade 1A ulcerations plantar to the metatarsal heads in neuropathic patients.

Clinical effect of wound depth in critical limb ischemia with tissue loss after endovascular treatment

Wound severity is assessed mainly by the Rutherford classification for critical limb ischemia (CLI) with tissue loss. The Rutherford classification is based on the extent of tissue loss; however, its classification criteria are ambiguous and do not include information regarding wound depth. We investigated the effects of wound depth on clinical outcomes in CLI with tissue loss after endovascular treatment (EVT). Between April 2007 and August 2013, we enrolled 210 consecutive patients (247 limbs) who received EVT for CLI with tissue loss. In the limbs examined, 271 individual wounds existed. We evaluated wound depth using the University of Texas grade (grade 1: superficial wound not involving the tendon, capsule, or bone, n = 97; grade 2: wound penetrating the tendon or capsule, n = 124; and grade 3: wound penetrating the bone or joint, n = 50). We also investigated the wound healing rate at 12 months and limb salvage and major amputation-free survival rates 3 years after EVT. The wound healing rates at 12 months in Texas 1, 2, and 3 were 88%, 48%, and 24%, respectively (log-rank P < .001). The limb salvage and major amputation-free survival rates at 3 years were lower in deep wounds than in shallow wounds (limb salvage rates: 98%, 82%, and 67%, respectively; P < .001; major amputation-free survival rates: 78%, 52%, and 42%, respectively; P < .001). In only minor tissue loss, the wound healing rates at 12 months and the limb salvage and major amputation-free survival rates at 3 years were stratified according to wound depth (wound healing rates: 92% in Texas 1 and 51% in Texas 2 or 3; P < .001; limb salvage rates: 99% in Texas 1 and 86% in Texas 2 or 3; P = .001; major amputation-free survival rates: 79% in Texas 1 and 57% in Texas 2 or 3; P = .001). In only major tissue loss, deep wounds also caused poor outcomes compared with shallow wounds (wound healing rates: 70% in Texas 1 and 36% in Texas 2 or 3; P = .019; limb salvage rates: 94% in Texas 1 and 73% in Texas 2 or 3; P = .050; major amputation-free survival rates: 75% in Texas 1 and 45% in Texas 2 or 3; P = .039). Wound depth is an important indicator of wound status and affects the clinical outcomes of CLI with tissue loss.

Development and Validation of a New Scoring System to Predict Wound Healing After Endovascular Therapy in Critical Limb Ischemia With Tissue Loss

Purpose: To develop a scoring system to predict wound healing in critical limb ischemia (CLI) patients treated with endovascular therapy (EVT). Methods: Between July 2007 and January 2013, 184 patients (118 men; mean age 73.0 years) with CLI (217 limbs) and tissue loss underwent EVT. From this cohort 236 separate wounds were divided into development (n=118) and validation (n=118) groups. Predictors of wound healing were identified using multivariable analysis. Each predictor was assigned a score based on its regression coefficient, and total scores were calculated, ranging from 0 to 1 for low risk up to ≥4 for high risk of a nonhealing wound. The performance of the scoring system in the prediction of wound healing was evaluated by calculating the area under the receiver operating characteristics (ROC) curve. Results: By multivariable analysis, a University of Texas grade ≥2 (HR 0.524, 95% CI 0.288–0.951, p=0.034), an infected wound (HR 0.497, 95% CI 0.276–0.894, p=0.020), dependence on hemodialysis (HR 0.459, 95% CI 0.259–0.814, p=0.008), no visible blood flow to the wound (HR 0.343, 95% CI 0.146–0.802, p=0.014), and major tissue loss (HR 0.322, 95% CI 0.165–0.630, p=0.001) predicted a non-healing wound. The 1-year rates of wound healing in the low-, intermediate-, and high-risk groups were 94.6%, 67.6%, and 9.1%, respectively, in the development group (p<0.001) and 92.3%, 70.5%, and 31.3%, respectively, in the validation sample (p<0.001). The area under the ROC curve was 0.922 in the development group and 0.808 in the validation sample. Conclusion: This scoring system reliably predicts wound healing in CLI patients after endovascular revascularization and is potentially helpful in deciding if additional adjuncts or revascularization should be considered.

TCT-525 Wound depth assessed by Texas grade affect wound healing in critical limb ischemia after endovascular therapy

TCT-525 Wound depth assessed by Texas grade affect wound healing in critical limb ischemia after endovascular therapy

Diabetic foot disease: grading inflammation by apolipoprotein A-I, C-reactive protein and serum amyloid A.

The different grading systems for diabetic foot disease pose a challenge in clinical decision making because each system fails to accurately reflect the individual course of disease progression. This study attempts to identify laboratory measurements for classifying diabetic foot disease to guide clinical treatment. The sera of 111 clinically graded diabetic foot patients were measured for several laboratory parameters including serum amyloid A (SAA), C-reactive protein (CRP), and apo A-I. By using the molar sum of CRP and SAA and then dividing by the molarity of apo A-I, an acute phase index was introduced to assess the inflammatory status of the patients. Based on a newly defined acute phase index (API), diabetic foot patients were classified into 3 distinct groups that provide a diagnostic tool complementing the established Texas grading system for clinical decision making. The integration of the serum concentrations of SAA, CRP and apo A-I into an acute phase index (API) offers an opportunity to triage diabetic foot patients who may benefit from personalized medicine.

Clinical Efficacy of the Pan Metatarsal Head Resection as a Curative Procedure in Patients with Diabetes Mellitus and Neuropathic Forefoot Wounds

To evaluate the safety and efficacy of the pan metatarsal head resection (PMHR) compared with nonsurgical management of wounds in the forefoot in people with diabetes. The authors evaluated 92 patients with diabetes (66.3% male), with ulcers classified as University of Texas grade 1A or 2A at the plantar aspect of the forefoot using a case-control model. Cases were patients treated with multiple metatarsal head resections for multiple metatarsal head wounds, and controls received standard nonsurgical care. Both groups received standard off-loading and wound care. Outcomes included time to healing, reulceration, infection, and amputation. Patients in the surgery group (SG) healed significantly faster than those in the standard therapy group (ST; 84.2 ± 39.9 days for the ST vs 60.1 ± 27.9 days for the SG; P = .003) and had fewer recurrent ulcers (39.1% for the ST vs 15.2% for the SG; P = .02; odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.3-9.7) and infections during 1 year of follow-up (64.5% for the ST vs 35.5% for the SG; P = .047; OR = 2.4; 95% CI = 1.0-6.0). There was no significant difference in the proportion of patients receiving an incident amputation in the follow-up period (13.0% for the ST vs 6.5% for the SG; P = .5). The results of this study suggest that the PMHR may be associated with shorter times to healing and lower morbidity compared with standard care alone in patients without digital gangrene and with multiple plantar forefoot ulcers.

New and Recurrent Ulcerations after Percutaneous Achilles Tendon Lengthening in Transmetatarsal Amputation

The purpose of the study was to review the incidence rate of new and recurrent ulcerations in transmetatarsal amputations after original ulcers healed with percutaneous Achilles' tendon lengthening as an isolated procedure. We reviewed 35 charts from period of January 1995 to March 2007, and 28 were included for the final review. Twenty-four ulcers were grade 1A, 2 were 0A and 1B, and 1 was 1C using the University of Texas Grading System. Time to heal of ulceration post-TAL was 9.4 weeks (range 3-72 weeks). For statistical analysis, we used binomial distribution for dichotomous variables. Results demonstrated 4 limbs did not heal, 10 patients had an ulcer recurrence (p<0.001), and 6 developed new ulcers. Of the 28 patients in which TAL was performed, 16 developed new neuropathic ulcers (including recurrent ulcers; p=0.0099). High recurrence and new ulcers formation exist after TAL in patients with an unbalanced metatarsal amputation, and extrinsic/ intrinsic factors may need to be addressed to prevent recurrence. 4.

Maggot Therapy in “Lower-Extremity Hospice” Wound Care

We sought to assess, in a case-control model, the potential efficacy of maggot debridement therapy in 60 nonambulatory patients (mean +/- SD age, 72.2 +/- 6.8 years) with neuroischemic diabetic foot wounds (University of Texas grade C or D wounds below the malleoli) and peripheral vascular disease. Twenty-seven of these patients (45%) healed during 6 months of review. There was no significant difference in the proportion of patients healing in the maggot debridement therapy versus control group (57% versus 33%). Of patients who healed, time to healing was significantly shorter in the maggot therapy than in the control group (18.5 +/- 4.8 versus 22.4 +/- 4.4 weeks). Approximately one in five patients (22%) underwent a high-level (above-the-foot) amputation. Patients in the control group were three times as likely to undergo amputation (33% versus 10%). Although there was no significant difference in infection prevalence in patients undergoing maggot therapy versus controls (80% versus 60%), there were significantly more antibiotic-free days during follow-up in patients who received maggot therapy (126.8 +/- 30.3 versus 81.9 +/- 42.1 days). Maggot debridement therapy reduces short-term morbidity in nonambulatory patients with diabetic foot wounds.

Evaluation of Removable and Irremovable Cast Walkers in the Healing of Diabetic Foot Wounds

The purpose of this study was to evaluate the effectiveness of a removable cast walker (RCW) and an "instant" total contact cast (iTCC) in healing neuropathic diabetic foot ulcerations. We randomly assigned 50 patients with University of Texas grade 1A diabetic foot ulcerations into one of two off-loading treatment groups: an RCW or the same RCW wrapped with a cohesive bandage (iTCC) so patients could not easily remove the device. Subjects were evaluated weekly for 12 weeks or until wound healing. An intent-to-treat analysis showed that a higher proportion of patients had ulcers that were healed at 12 weeks in the iTCC group than in the RCW group (82.6 vs. 51.9%, P = 0.02, odds ratio 1.8 [95% CI 1.1-2.9]). Of the patients with ulcers that healed, those treated with an iTCC healed significantly sooner (41.6 +/- 18.7 vs. 58.0 +/- 15.2 days, P = 0.02). Modification of a standard RCW to increase patient adherence to pressure off-loading may increase both the proportion of ulcers that heal and the rate of healing of diabetic neuropathic wounds.

Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen.

To evaluate the activity of patients with diabetic foot ulcerations and their adherence to their pressure off-loading device. We enrolled 20 subjects treated for neuropathic diabetic foot wounds corresponding to University of Texas grade 1 stage A. All were off-loaded using a removable cast walker (RCW). We recorded the total activity (measured in activity steps per day) taken on a waist-worn computerized accelerometer. We subsequently correlated this to activity recorded on an RCW-mounted accelerometer, which was not readily accessible to the patient. There were a mean 1219.1 +/- 821.2 activity units (steps) taken per patient per day. Patients logged significantly more daily activity units with the protective RCW off than with it on (873.7 +/- 828.0 vs. 345.3 +/- 219.1, P = 0.01). This amounts to only 28% of total daily activity recorded while patients were wearing their RCW. Although a total of 30% of the patients in the study recorded more daily activity units while wearing the device, this subset most adherent to their off-loading regimen still only wore the device for a total of 60% of their total daily activity. Subjects with diabetic foot ulcerations appear to wear their off-loading devices for only a minority of steps taken each day. This may partially explain the poor results reported from many trials of agents designed to help speed the healing of these wounds. Control of this important aspect of care with less easily removable devices may increase the prevalence of healing.

Assessment of cardiac rejection by MR-imaging and MR-spectroscopy.

Detection of cardiac rejection is a major problem in cardiac transplantation. The gold standard is, and remains, endomyocardial biopsy. Evaluation of MR-imaging and MR-spectroscopy for detection of cardiac rejection. Orthotopic cardiac transplantation (HTX) was performed in 13 pigs (body weight 30 kg). All animals obtained immunosuppressive (triple) therapy for 1 week after the operation. Thereafter immunosuppression was stopped to induce cardiac rejection. MRI and MRS (1.5 Tesla General Electrics Signa) were performed pre- and post-operatively on days 10, 17, 24 and 31. The degree of rejection was determined post-operatively using endomyocardial biopsy (Texas grading score). (1) MR-imaging: LV function remained unchanged after HTX. LV mass increased (+42%; P < 0.05) with cardiac rejection. (2) MR-spectroscopy: a marked reduction in the ratio of phosphocreatine and adenosine triphosphate, respectively, to inorganic phosphate was observed in the rejecting hearts. (3) Histologic grading confirmed cardiac rejection after stopping immunosuppression. The Texas score was 5.7+/-0.8 at autopsy. MR-imaging and MR-spectroscopy allow the detection of changes associated with cardiac rejection. Both techniques are correlated with histologic rejection. However, endomyocardial biopsy remains the gold standard for reliable detection of cardiac rejection.