Trophic Ulcers Research Articles

A Response to Article "Effectiveness of Secretome from Human Umbilical Cord Mesenchymal Stem Cells in Gel (10% SM-hUCMSC Gel) for Chronic Wounds (Diabetic and Trophic Ulcer) - Phase 2 Clinical Trial" [Letter

A Response to Article "Effectiveness of Secretome from Human Umbilical Cord Mesenchymal Stem Cells in Gel (10% SM-hUCMSC Gel) for Chronic Wounds (Diabetic and Trophic Ulcer) - Phase 2 Clinical Trial" [Letter

Insulin eye drops for treating corneal ulcer in a non-diabetic patient: regarding a case

Corneal ulcers are included in a heterogeneous group of eye injuries. When patients do not respond to treatment, including even corneal transplant, other alternatives need to be explored.We present a case of a patient who suffered an accidental spillage from the contents of a car battery. This corneal lesion was refractory to both surgical and pharmacological treatment. After four years of a persistent ulcer, insulin topical treatment 50 IU/mL was started. Improvement began to be observed and currently the patient has completely recovered the corneal epithelium.Nowadays, evidence of the topical insulin use for the treatment of corneal ulcers is higher in diabetic patients. In non-diabetic patients, evidence is restricted to a series of cases of neurotrophic corneal ulcers and a case report of a patient who presented a persistent epithelial defect after resection of a neurinoma. This case presents the experience of using an insulin drop formulation with effectiveness and absence of toxicity in a patient non-diabetic with a post-caustic corneal ulcer.

Гематологические индексы – новые маркеры воспалительной активности у больных с трофическими язвами нижних конечностей в пожилом, старческом возрасте и у долгожителей

Aim. To study the significance of various hematological indices as markers of laboratory inflammatory activity in patients with trophic ulcers of the lower extremities and compare them with similar indices in old patients with coronary artery disease (CAD). Materials and methods. The study enrolled 256 patients; 166 patients with trophic ulcers – in the main group, 90 with CAD, but without ul-cers – in the comparison group. The main group consisted of 31.9% men and 68.1% women. The mean age of patients with trophic ulcers reached 80.8±10.1 years (from 61 to 101 years); 30.1% of patients were centenarians. The ratio of the number of neutrophils to lymphocytes (NLR), neu-trophils to monocytes (NMR), platelets to lymphocytes (PLR), lymphocytes to monocytes (LMR) and systemic immune-inflammation index (SII –platelet count хNLR) were determined. Results. The mean count of leukocytes in patients with trophic ulcers was 7.1±2.6×109/l, neutrophils – 4.7±2.3×109/l, lymphocytes –1.8±2.2×109/l, monocytes – 0.6±0.3×109/l, platelets – 278.5±110×109/l. The mean values of NLR in the group of patients with ulcers reached 3.6, NMR – 15.4, PLR – 214.1, LMR – 5.9, SII – 1102.3. In patients with trophic ulcers, the count of leukocytes (6.7×109/l and 5.9×109/l; p=0.002), neutrophils (4.2×109/l and 3.7×109/l; р=0.002) and platelets (252×109/l and 205×109/л; p<0.0001) was significantly higher than in the group of patients with CAD. NLR (2.7 and 2.1; p=0.003) and PLR (172 and 133; p<0.0001) in patients with trophic ulcers of the lower extremities was higher, but LMR was lower (2.8 and 3.1; p=0.01), than in patients with CAD. In the group of patients with trophic ulcers, the median of the SII reached 452, while in patients with CAD it was 296 (p=0.00003). The median of erythrocyte sedimentation rate in patients with the lower ex-tremities ulcers was 32 mm/h, in patients with CAD – 21 mm/h (p=0.00002).A direct relationship was registered between interleukin-6 level and leukocytes (r=0.32; p=0.01), neutrophils (r=0.36; p=0.005), platelets (r=0.36; p=0.006), NLR (r=0.30; p=0.02), PLR (r=0.27; p=0.03) and SII (r=0.31; p=0.01). Conclusions. The study results suggest that various hematological indices can be used as markers of laboratory inflammatory activity in patients with trophic ulcers of the lower extremities in the old age and centenarians.

Modern ideas about the mechanisms of development of valvular insufficiency in chronic venous insufficiency

Annotation. Despite the improvement of methods of diagnosis and treatment of chronic venous insufficiency of the lower extremities, this problem remains relevant and not fully resolved. The confirmation is a large percentage of patients with trophic changes, as a result of deep disorganization of the venous wall and valves in the system of deep and superficial veins. The purpose of this article is to conduct a literature analysis of the various mechanisms of the development of valvular insufficiency in order to improve the treatment of patients with chronic venous insufficiency. A scientific search was carried out for the period from 2000 to 2022 according to the primary search strategy “valvular failure of the veins of the lower extremities”, and the AND/OR combination in the scientific databases MEDLINE (PubMed), Scopus, Web of Science. Among practicing doctors, there are two views on the initial levels of the formation of valvular insufficiency in varicose disease: the beginning of varicose transformation is associated with the expansion of individual venous branches, and the failure of the main trunks of the subcutaneous veins joins much later. Another factor in the pathogenesis of trophic changes in chronic venous diseases is changes in the viscoelastic properties of the walls of deep veins, which lead to valvular insufficiency and impaired venous outflow. The main cause of trophic ulcers in patients with chronic venous insufficiency is the formation of persistent pathological vertical reflux in the system of deep and superficial veins and the presence of horizontal reflux at the level of communicating and penetrating veins of the lower third of the thigh. Orthostatic venous stasis causes a progressive violation of venous hemodynamics and leads to deterioration of microcirculation and disruption of tissue nutrition.

JET+PCB strategy in the treatment of superficial femoral artery occlusion: a case report

Сritical limb ischemia (CLI) is becoming more and more common among patients worldwide. This is a comorbid condition, which is accompanied by chronic pain, sometimes trophic ulcers and gangrene, as well as a decrease in the quality of life. Despite the chronic nature of ischemia, the absence of treatment is accompanied by a high incidence of limb amputation and death. Patients with lower limb atherosclerosis had the higher risk of cardiovascular events and death. This publication proposes to consider minimally invasive interventional arterial revascularization in a 63-year-old patient with intermittent claudication, stage III critical limb ischemia, with a history of bilateral superficial femoral artery (SFA) stenting. Control lower limb angiography showed bilateral SFA occlusion and thrombosis. Taking into account the restenosis of the previously implanted stent, JET+PCB strategy was considered: first stage — rotational atherectomy followed by SFA angioplasty with a drug-eluting balloon catheter. The correct choice of minimally invasive surgery method in combination with non-pharmacological (smoking cessation, training walking) and pharmacological methods made it possible to restore viability and preserve the lower limb without negative consequences for the patient's health.

Интерлейкин-6 у больных пожилого и старческого возраста с трофическими язвами нижних конечностей

Aim. To study the pathogenetic role of interleukin-6 (IL-6) in old patients with trophic ulcers of the lower extremities. Methods. The study enrolled 66 patients suffered from trophic ulcers of the lower extremities. The mean age of study patients reached 77.1±9.1 years (62–97 years). The majority of patients (65.1%) were women. The concentration of IL-6 in the blood (n<7.0 pg/ml) was determined by enzyme immunoassay. Results. Increased level of IL-6 was found in 77.3% of patients. The mean concentration of IL-6 was 14.9±14.6 pg/ml (1.5–288.6 pg/ml), median – 10.7pg/ml. The mean values of interleukin-6 in patients with venous ulcers reached 12.7 pg/ml, arterial – 13.4 pg/ml, mixed – 26.7 pg/ml (p=0.01). Direct correlation was registered between IL-6 level and the number of ulcers (r=0.3; p=0.02). There was a direct correlation between IL-6 concentration and the ulcers duration (r=0.28; p=0.03). There was a trend towards a direct correlation between interleukin-6 and ulcers size (r=0.23; p=0.08). In patients with infected ulcers, the mean IL-6 level was 17.5 pg/ml, in patients without microbiological growth – 11.6 pg/ml, but these differences did not reach the statistical significance (p=0.3). Significant direct correlations were established between IL-6 concentration and the level of C-reactive protein (r=0.61; p<0.000001), leukocyte count (r=0.36; p=0.006), neutrophil count (r=0.39; p=0.002), platelet count (r=0.39; p=0.002), ESR (r=0.40; p=0.003), inverse correlation – with hemoglobin (r=-0.41; p=0.001). There was a direct correlation between IL-6 level and severity of frailty (r=-0.38; p=0.03) and inverse correlation – with instrumental activity in daily life scale (r=-0.35; p=0.03). Patients with elevated IL-6 concentration had higher CRP (18.3 and 6.7 mg/l; p=0.001) and ESR (42.5 and 28.1 mg/l; p=0.04mm/h), but lower hemoglobin levels (114.3 and 125.9 g/l; p=0.01). There was a tendency to a direct correlation between IL-6 level and the age of study patients (r=0.23; p=0.06). Conclusion. Study results indicate a frequent increase in the interleukin-6 level in old patients with trophic ulcers of lower extremities. An increase in IL-6 concentration is associated with number and duration of ulcers as well as with various hematological parameters.

Трофические язвы нижних конечностей у долгожителей: есть ли особенности?

Aim. To compare various clinical and laboratory parameters in centenarians and old patients with trophic ulcers of the lower extremities. Materials and methods. 100 patients were enrolled in the cross-sectional study; 45 centenarians with trophic ulcers – in the main group, 55 patients with trophic ulcers younger than 90 years – in the control group. The age of study patients varied from 61 to 101 years, averaging 82.9±10.5 years. The majority of study patients were women (70%). Results. 40% of ulcers in centenarians were venous ulcers, 24.4% – arterial, 20% – mixed ulcers. Centenarians had a smaller number of ulcers (p=0.03), a shorter duration of ulcers (p=0.01), a smaller area and less infection, compared with patients younger than 90 years. Atrial fibrillation was registered in 46.7% of centenarians, while in patients younger than 90 years this arrhythmia was observed in 31.4% of cases (p=0.02). 22.2% of centenarians and 43.4% of patients under 90 years of age suffered from diabetes mellitus (p=0.001). 11.1% of centenarians and 18.9% of patients of old age suffered stroke in the past (p<0.001). There were no differences in the incidence of myocardial infarction in history (p=0.92) and chronic heart failure (p=0.97) between groups of patients. Among centenarians, 45.2% of patients had normal body weight, 31% were overweight, 23.8% were obese, while in the group of patients younger than 90 years, obesity was registered in 53.7%, and only 22.2 of patients had a normal body mass index (p=0.001). The body mass index in centenarians reached an average of 27.2±6.0 kg/m2, in elderly and senile patients it was 33.7±11.2 (p<0.0001), and the weight was 67.9±16.3 kg and 92.2±33.2 kg, respectively (p<0.0001). The mean count of leukocytes in centenarians was 6.4±2.3×109/l, in patients younger than 90 years – 7.3±2.8×109/l (p=0.07), and platelets – 233±87×109/l and 291±117×109/l, respectively (p=0.006). The mean level of C-reactive protein in centenarians was 12.4±14.7 mg/l, and in patients younger than 90 years it was 26.5±34.0 mg/l (p=0.04). An inverse correlation was observed between the level of C-reactive protein and the age of patients (r=-0.49; p<0.0001). In the group of centenarians a direct correlation was registered between ESR and C-reactive protein level (r=0.49; p=0.02). Conclusions. The study results indicate a number of features of various clinical and laboratory parameters in centenarians with trophic ulcers of the lower extremities, compared with similar old patients.

Congenital Insensitivity TO Pain: A Case Report

Congenital insensitivity to pain or more scientifically Hereditary sensory and autonomic neuropathies (HSAN) is a rare genetic disorder which associates a sensory dysfunction with a varying degree of autonomic dysfunction. Due to the peripheral neuropathy, a decreased sensitivity or even complete anesthesia may be present resulting in, on the ophthalmological level, neurotrophic ulcers. We report the case of 2 sisters (JM and KM) presenting with HSAN with recurrent corneal ulcers. Unfortunately, genetic testing couldn’t be performed due to lack of means, but the clinical presentation and features were very favourable or even pathognomonic of this syndrome. The first cases or reported individuals presenting with congenital insensitivity to pain goes back to 1930’s. Five types of hereditary sensory and autonomic neuropathy have been identified according to age of onset of symptoms, clinical features and affected gene. HSAN type IV also known as congenital insensitivity to pain with anhidrosis (CIPA) is the second most common HSAN. It is caused by mutation in the NTRK1(Neurotrophic tyrosine kinase receptor type 1) (TRKA) gene located in chromosome 1 (1q21-q22). It is characterized by repetitive hyperthermic episodes in infancy, and mental retardation is usually present, as reported in our case. Clinical symptoms of pain insensitivity manifest as tongue, lip and fingers biting, and self-inflicted injuries. Congenital insensitivity to pain is a rare genetic syndrome characterized by an absence or an altered response to pain. Individuals with this syndrome can presented self-inflicted injuries and auto-mutilation leading in some cases to severe disabilities. Long-term visual prognosis in CIPA patients is not assessed and there’s an important lack of data regarding ocular manifestation of CIP syndrome.

Syndrome of lymphovenous insufficiency in diseases of the lower limb veins. View from the position of a lymphologist

Purpose of the study: to assess the state of the lymphatic bed and develop methods of lymphatic influence to improve the results of treatment of diseases of the veins of the lower extremities.Material and methods. 692 patients with diseases of the veins of the lower extremities were examined, in whom special methods for studying phlebo- and lymphodynamics, microcirculation and regional immunity were carried out. Of these, 153 patients with acute superficial thrombosis; 154 - with deep vein thrombosis; 385 - with chronic venous insufficiency. The main group - 405 patients, using lymphological methods of treatment, the control group - 287 patients, using traditional treatment, according to clinical recommendations.Results. Radionuclide lymphoscintigraphy revealed that with thrombosis of the veins of the lower extremities at the onset of the disease, the rate of lymph flow increased by 1.2 times (p < 0.005), and the intensity of radionuclide absorption increased by 9.3% (p < 0.05) relative to healthy people. From 12-15 days of the disease, the rate of lymph flow decreased by 1.4 times (p < 0.05), and the intensity of radiopharmaceutical excretion decreased by 25% (p < 0.005). Chronic venous insufficiency is accompanied by impaired lymph flow of varying severity. The disorders increased as the degree of venous insufficiency increased. Against the background of the use of lymphological approaches in patients with lymphovenous insufficiency syndrome, at the level of statistically significant differences, the rate of lymph flow increased, microcirculation and regional immunity were restored, which contributed to a significant improvement in both immediate and long-term results of treatment. In patients with trophic ulcers, there was an acceleration in the timing of clearance, granulation and epithelialization compared with conventional treatment (p < 0.05).Conclusion. Diseases of the veins of the lower extremities, accompanied by phlebohypertension, already at the earliest stages of the disease lead to significant changes in the lymphatic system, with characteristic manifestations. The use of methods of conservative and surgical lymphogenous correction improves the results of treatment of the pathology in question.

A prospective study on efficacy of Platelet Rich Fibrin (PRF) in the management of trophic ulcers of leprosy

A prospective study on efficacy of Platelet Rich Fibrin (PRF) in the management of trophic ulcers of leprosy

Platelet-rich fibrin therapy in the management of nonhealing trophic ulcers due to underlying leprous neuropathy.

Autologous platelet-rich fibrin (PRF) therapy is beneficial in the treatment of nonhealing ulcers. We present a case series of nonhealing, trophic ulcers with underlying leprous neuropathy, treated successfully with PRF therapy. It was a prospective study, conducted in a tertiary care hospital in the western Maharashtra, India between April 2021 and March 2022. A total of 11 patients with 18 nonhealing trophic ulcers were included in the study and consisted of 8 men and 3 women. The patient's median age was 41 years (range, 33-68), the median size of the ulcers was 4 cm2 (range: 1-12 cm2), the median duration of ulcers was 20 weeks (16-30 weeks), and time to heal after starting treatment was 4 weeks (range: 1-8 weeks). PRF is an easy-to-use, simple, safe, effective, and economical treatment for the management of trophic ulcers.

Modern approaches in the treatment of occlusive restenosis of the arteries of the lower extremities. Case report

Chronic lower limb ischemia is becoming increasingly common among patients worldwide. This is a comorbid condition, which is accompanied by chronic pain, trophic ulcers and gangrene, as well as a decrease in the quality of life. Despite the chronic nature of ischemia, the absence of treatment is accompanied by a high rate of limb amputation and mortality. It has been proven that in patients with peripheral arterial disease of the lower extremities, the risk of cardiovascular events and mortality increases. The publication proposes to consider the tactics of minimally invasive arterial revascularization in a patient with occlusive restenosis of the right superficial femoral artery. The correct choice of minimally invasive surgical treatment in combination with a complex of both non-drug (walking) and drug methods made it possible to restore viability and preserve the lower limb without unfavorable consequences for the patient’s health.

Effectiveness of Secretome from Human Umbilical Cord Mesenchymal Stem Cells in Gel (10% SM-hUCMSC Gel) for Chronic Wounds (Diabetic and Trophic Ulcer) - Phase 2 Clinical Trial.

Chronic wounds carry financial burdens and increase morbidity and mortality, especially in diabetic ulcers and Hansen's Morbus. More than 50% of chronic ulcers are difficult to heal with regular treatment and require new types of therapy such as the use of secretome of human umbilical cord mesenchymal stem cells (SM-hUCMSC). This experimental study was carried out to see the effectiveness of using SM-hUCMSC in diabetic ulcers and Hansen's Morbus in four medical facilities (multicentre). The level of active secretion has been measured by default in 10% SM-hUCMSC gel, used as a treatment intervention. The primary outcome is wound healing in terms of the length, width, and extent of the wound. The secondary is the side effects of treatment 2 weeks after administration. Follow-up visits will be scheduled at 1 and 2 weeks post-treatment. Forty-one chronic ulcers successfully followed the study until the end. In patients with chronic ulcers, the mean ulcer length, width, and area were 1.60 (0,50-13,0), 1.3 (0,5-6,0), and 2.21 (0,25-78) cm square, respectively, before interventions and 1 (0-12), 0,8 (0-6,0), and 1 (0-72) square cm after interventions at the second follow-up. The change between the beginning and end of the intervention was significant (p-value <0.05). The use of 10% SM-hUCMSC gel topically has been proven effective in accelerating the process of wound healing, especially chronic ulcers with side effects that are not present in this study.

Experience in complex therapy of lower limb trophic ulcers of venous and diabetic origin

Trophic ulcers (TU) associated with venous circulation pathology or diabetes mellitus are considered chronic wounds with all the attributes of the complex extracellular matrix (ECM) reorganization and tissue remodelling of the edges and bed of these wounds. It was therefore determined that only a comprehensive step-wise approach to the treatment of TU can produce a stable clinical result. The article presents the experience of comprehensive management of venous and diabetic TUs. Three clinical cases of management of patients with lower limb TUs are described. The treatment of patients was planned taking into account the accepted algorithms for the management of TU associated venous circulation pathology or diabetes mellitus. The topical therapy included advanced wound coverings. The choice of dressing was determined by the clinical course of wound process. Alginate dressings were used on stages I and II wounds; hydrocolloid dressings were used on stages II and III wounds. Effects resulting from treatment included almost complete healing or readiness of a TU for skin grafting. The topical therapy of venous and diabetic TUs is part of the comprehensive treatment. During phase 1 wound process, the topical drugs should have antimicrobial, necrolytic, draining, osmotic and analgesic action. During phase 2, the granulation tissue should be induced and the balanced moist environment should be created to promote tissue regeneration. The wound coverings specified in the above clinical examples are fully consistent with the principles of the TIME concept, their ease of use and comfort for the patient are pointed out.

Chronic compartment-syndrome of the lower limb: modern strategies for diagnosis and treatment

A review of the literature is presented, including data on the incidence, pathophysiology, and clinical picture of patients with chronic compartment syndrome (CCS) of the lower extremities. Chronic exercise compartment syndrome (CECS) is characterized by pain with repetitive exertion and increased intracompartmental pressure affecting the lower extremities in physically active patients. In severe chronic venous insufficiency of the lower extremities, chronic venous compartment syndrome (CVCS) develops, which is fundamentally different from previously known clinical pictures. Progressive dermatolipofasciosclerosis and cicatricial destruction of the fascia of the leg in patients with C4b-C6 clinical classes according to CEAP affect the pressure in the muscle-fascial compartments at each step. In severe cases, this leads to significant changes in the muscles, accompanied by chronic ischemia associated with necrosis and glycogen deficiency. The analysis of various diagnostic methods, conservative treatment and methods for performing surgical decompression of the CCS was carried out. The lack of a clear pathophysiology for CECS and CVCS complicates the diagnosis and treatment of this condition. Diagnosis of calf CCS is still based on pressure testing in the musculofascial compartments of the calf using the Pedowitz criteria, however standard procedures for this, including patient position, static or dynamic movements, muscles and equipment tested, are not agreed upon. In patients with CCS, if conservative treatment is ineffective, fasciotomy of the affected parts of the lower leg is the method of choice. Various techniques for fasciotomy of the lower leg include the traditional open fasciotomy, the semi-closed technique with one or more incisions, the minimally invasive technique using endoscopic compartment release, and the use of ultrasound guidance. Fasciectomy of the lower leg to correct CVCS is performed mainly for recurrence of trophic ulcers after shave therapy, severe calcification of the lower leg tissues and for the treatment of deep transfascial necrosis. Randomized, blinded, controlled trials are needed to further expand our knowledge of the diagnosis and treatment of CCS.

Successful management of 30 kg Gigantic para-testicular liposarcoma

We report the successful management of a paratesticular liposarcoma, which, to the best of our knowledge, is the largest known of its type. A 62-year-old male presented with a painless, gradually progressive left testicular “giant” mass measuring 60 × 40 cm, weighing 30 kg and growing over a period of three 3 years. Additionally, a 5 × 5 cm trophic ulcer could be seen at the bottom of the scrotum. The ultrasound of the left testis revealed the testis having been completely replaced with a cystic and solid tumour. Preoperative serum testicular tumour markers (STM) were within normal limits. The markers included Alpha Feto Protein, Beta Human Chorionic Gonadotropin and Lactose Dehydrogenase. A left sided high inguino-scrotal approach with a huge skin resection including the trophic ulcer with complete removal of the tumour and a primary complex closure of the wound was performed. The post-operative period was uneventful, and histopathology revealed a dedifferentiated liposarcoma. We believe social taboo and fear of disfigurement impart a sense of shame in patients which led to the delayed presentation in a hospital in the index patient. The absence of metastases even with a protracted course is surprising.

P-014 SURGICAL TREATMENT OF COMPLEX INCISIONAL HERNIAS

Abstract Aim to study the early and long-term outcomes of the abdominal wall reconstruction (AWR) of complex incisional hernias. Material &amp; Methods We retrospectively reviewed prospectively collected data from 121 patients with 1 to 7 years of follow-up, who underwent midline AWR between 2015 and 2022. The complexity of hernia was determined according to the criteria of N. J. Slater et all. All patients had a hernia gate width ≥10cm (W3). “Loss of domain”≥20% had 38% of patients, a recurrence after previously performed mesh-reinforced AWR (R1–5) - 36%, purulent fistulas, trophic ulcers and chronic seromas - 9%. Three laparotomies or more in anamnesis had 48.7% patients. Obesity had 74.4%; type II diabetes mellitus - 26.5%; COPD - 15.7%. Mesh-reinforced fascial repairs were used in 73 (60.33%) cases, bridged repairs were used in 48 (39.67%) cases. Results Wound complications in the early postoperative period were observed in 48 (40.5%) patients. Long-term outcomes: recurrence hernia - 7 (5.8%), ligature fistula - 3 (2.5%), chronic wound - 2 (1.6%), pseudocyst - 3 (2.5%), building of the mesh - 7 (5.8%). Mesh-reinforced AWRs with primary fascial coaptation resulted in fewer hernia recurrences (2.7% vs 10.4%) and fewer wound (31.5% vs 52.2%) and overall (5.5% vs 16.6%) complications than bridged repairs. At the same time, bridged repairs resulted in fewer postoperative pain (9.6% versus 4.2%) than mesh-reinforced AWRs. Conclusions Surgical treatment of patients with complex incisional hernias requires the use of combined techniques for AWR using a mesh, which reduces the recurrence to 5.8%.

Modern approaches to the treatment of trophic ulcers of venous etiology: photodynamic therapy

Chronic venous insufficiency, being the outcome and complication of most diseases of the veins of the lower extremities, is the fundamental cause of the formation of trophic ulcers. Over the past decade, in solving the problem of treating venous trophic ulcers, certain successes have been achieved, both in theoretical and practical terms. The modern concept of curation of patients with trophic ulcers of venous origin involves a reasonable combination of the following methods of treatment: local, including compression, as well as medical, surgical, minimally invasive and additional methods (physiotherapy, photodynamic therapy, etc.). The main goal of the treatment is to eliminate the ulcer, after which measures are taken to correct the underlying cause (chronic venous insufficiency) and prevent relapse. However, the tactics of the most successful treatment of patients with trophic ulcers of venous etiology is still not defined and requires further improvement. In particular, the method of photodynamic therapy, which includes the usage of special drugs - photosensitizers, also deserves to be studied and expanded for clinical use. The mechanism of photodynamic action is based on the ability of photosensitizers to accumulate in microbial and pathological cells. Under local light exposure, the photosensitizer enters an excited state and charges oxygen, which is associated with erythrocyte hemoglobin. Thus, in cells under the influence, a photochemical reaction is triggered, which ensures the formation of singlet oxygen and its free radicals. Reactive oxygen species, in turn, have a damaging effect on pathogenic flora and necrotic tissues. The main advantages of the method are relative simplicity, no risk of developing antibiotic resistance, acceleration of reparative and regenerative processes, and prevention of secondary infection. Thus, photodynamic therapy allows non-invasive, safe and effective optimization of local treatment and preoperative preparation of patients with venous trophic ulcers.

Rehabilitation Challenges in Orthotic Offloading with Dual Disability Involving Bilateral Lower Limbs with Right Transtibial Amputation for Charcot Joint, Left Neuropathic Foot of Hereditary Motor and Sensory Neuropathy Aetiology

Orthotic management of offloading neuropathic foot in hereditary motor and sensory neuropathy (HMSN) is challenging due to motor, sensory and functional deficits which may interfere with weight distribution over the foot. The challenge further becomes difficult with the involvement of the contralateral lower limb with below-knee amputation. This study is regarding challenges in offloading, weight transmission and distribution during the stance phase of gait in the case of a 35-year-old female with a left neuropathic foot due to HMSN with concomitant right transtibial amputation. The energy expenditure and cosmetic issues for the right lower limb and aiming for maximum functional conservation of the left foot, were considered by taking into account the heel pad thickness measured by musculoskeletal ultrasound, dynamic plantar pressure measured by footplate pressure measurement, the integrity of the ankle joint mobility and stability by clinical assessment, the electrophysiological status of the neuropathic foot by nerve conduction study and the weight-bearing capability of the right below-knee stump. The following management measures are planned for effective offloading with therapeutic footwear modification with silicone gel cushion heel and insole and rocker bottom outsole as an alternative to conventional weight-relieving calliper in a government tertiary care set-up, thereby conserving the foot function and morphology. This will help in planning a structured rehabilitation programme which will be beneficial in preventing future foot changes including trophic ulceration and subsequent amputation. Case follow-up after patient education and assessment of disease progression in each visit is being done. A better outcome in terms of quality of life and level of independent ambulation with concomitant bio-functionality of the left neuropathic foot was accomplished with community ambulation.

Criteria for evaluating the main signs of trophic ulcers and microcirculation in chronic venous insufficiency

Criteria for evaluating the main signs of trophic ulcers and microcirculation in chronic venous insufficiency