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1.  Major limb amputations: an audit of indications in a suburban surgical practice. 
BACKGROUND: Advancements in vascular and microsurgery in developed countries have led to fewer major limb amputations. AIM: This audit of major limb amputations performed at the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria, between June 1998 and May 2003, was conducted to find out the indications for amputation and highlight those cases that could be salvageable. PATIENTS AND METHODS: This was a retrospective study. Case notes of all patients who had major limb amputations were examined for patients' age, sex, time of presentation, limb affected, indications for amputation, the severity of crush injury to limb, stage of musculoskeletal tumors and Wagner's grade of diabetic foot. RESULTS: A total of 71 limbs were amputated in 69 patients; 56 limbs (78.1%) were unsalvageable, while 15 limbs (21.1%) were salvageable. Trauma accounted for 76% followed by 22% performed due to gangrene secondary to diabetes mellitus. Out of the 56 unsalvageable limbs, 31 patients presented with severely crushed limbs. Out of the 15 salvageable limbs, there were 11 cases of clean-cut traumatic amputations, two of soft-tissue sarcoma and one each of ruptured popliteal aneurysm and stenosed popliteal artery. CONCLUSION: Trauma and diabetes mellitus were leading indications for amputation. Expertise in limb salvage procedures and availability of appropriate equipment may reduce the numbers of amputations performed.
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PMCID: PMC2568563  PMID: 15719875
2.  Diabetic foot infections: current concept review 
Diabetic Foot & Ankle  2012;3:10.3402/dfa.v3i0.18409.
The purpose of this manuscript is to provide a current concept review on the diagnosis and management of diabetic foot infections which are among the most serious and frequent complications encountered in patients with diabetes mellitus. A literature review on diabetic foot infections with emphasis on pathophysiology, identifiable risk factors, evaluation including physical examination, laboratory values, treatment strategies and assessing the severity of infection has been performed in detail. Diabetic foot infections are associated with high morbidity and risk factors for failure of treatment and classification systems are also described. Most diabetic foot infections begin with a wound and once an infection occurs, the risk of hospitalization and amputation increases dramatically. Early identification of infection and prompt treatment may optimize the patient's outcome and provide limb salvage.
doi:10.3402/dfa.v3i0.18409
PMCID: PMC3349147  PMID: 22577496
diabetic foot infection; ulcer; guidelines; surgery
3.  Distal amputations for the diabetic foot 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.21288.
Minor amputations in diabetic patients with foot complications have been well studied in the literature but controversy still remains as to what constitutes successful or non-successful limb salvage. In addition, there is a lack of consensus on the definition of a minor or distal amputation and a major or proximal amputation for the diabetic population. In this article, the authors review the existing literature to evaluate the efficacy of minor amputations in this selected group of patients in terms of diabetic limb salvage and also propose several definitions regarding diabetic foot amputations.
doi:10.3402/dfa.v4i0.21288
PMCID: PMC3714676  PMID: 23869251
diabetic foot infections; amputations; diabetic neuropathy
4.  The mangled extremity and attempt for limb salvage 
Background
The decision, whether to amputate or reconstruct a mangled extremity remains the subject of extensive debate since multiple factors influence the decision.
Methods
Sixty three patients with high energy extremity trauma and attempts at limb salvage were retrospectively reviewed. We analyzed 10 cases of massive extremity trauma where there was made an attempt to salvage limbs, although there was a controversy between salvage and amputation.
Results
All of the patients except one had major vascular injury and ischemia requiring repair. Three patients died. All of the remaining patients were amputated within 15 days after the salvage procedure, mainly because of extremity sepsis. Seven patients required treatment at the intensive care unit. All patients had at least 2 reconstruction procedures and multiple surgical debridements.
Conclusion
The functional outcome should be considered realistically before a salvage decision making for extremities with indeterminate prognosis.
doi:10.1186/1749-799X-4-4
PMCID: PMC2646708  PMID: 19216787
5.  Free Tissue Transfer for Limb Salvage in High-Risk Patients: Worth the Risk 
Advances in Wound Care  2013;2(2):63-68.
Significance
Mircosurgical free tissue transfer is a powerful tool in the arsenal of reconstructive surgeons, oftentimes as the final option in limb salvage before amputation. Patients presenting for limb salvage frequently carry with them multiple co-morbidities such as diabetes mellitus, end-stage renal disease, and peripheral vascular disease. Surgeons are oftentimes hesitant to attempt free tissue tranfer in these medically complex individuals due to beliefs that the patient would not tolerate prolonged anesthesia, the surgery is doomed to fail, or the patient would be better off with an amputation. Because amputees actually demonstrate higher mortality rates, the decision to not to proceed with limb salvage should be made with great care.
Recent Advances
By reviewing the success rates with free tissue transfer for limb salvage in high-risk patients, the target articles have shown that this option is indeed viable even in this patient population. Specifically, reasonable success rates are presented for limb salvage using free tissue transfer in patients with end-stage renal disease, a single-vessel leg and critical limb ischemia.
Critical Issues
The articles reviewed demonstrate that free tissue transfer for limb salvage in properly selected patients with end-stage renal disease or severe peripheral vascular disease is worth attempting. Before surgery, these patients must undergo a complete cardiac work-up regardless of previous cardiac history.
Future Directions
When necessary, free tissue transfer should be pursued by the reconstructive surgeon even in high-risk medically complex patients.
doi:10.1089/wound.2011.0309
PMCID: PMC3840480  PMID: 24527327
6.  Contemporary Evaluation and Management of the Diabetic Foot 
Scientifica  2012;2012:435487.
Foot problems in patients with diabetes remain a major public health issue and are the commonest reason for hospitalization of patients with diabetes with prevalence as high as 25%. Ulcers are breaks in the dermal barrier with subsequent erosion of underlying subcutaneous tissue that may extend to muscle and bone, and superimposed infection is a frequent and costly complication. The pathophysiology of diabetic foot disease is multifactorial and includes neuropathy, infection, ischemia, and abnormal foot structure and biomechanics. Early recognition of the etiology of these foot lesions is essential for good functional outcome. Managing the diabetic foot is a complex clinical problem requiring a multidisciplinary collaboration of health care workers to achieve limb salvage. Adequate off-loading, frequent debridement, moist wound care, treatment of infection, and revascularization of ischemic limbs are the mainstays of therapy. Even when properly managed, some of the foot ulcers do not heal and are arrested in a state of chronic inflammation. These wounds can frequently benefit from various adjuvants, such as aggressive debridement, growth factors, bioactive skin equivalents, and negative pressure wound therapy. While these, increasingly expensive, therapies have shown promising results in clinical trials, the results have yet to be translated into widespread clinical practice leaving a huge scope for further research in this field.
doi:10.6064/2012/435487
PMCID: PMC3820495  PMID: 24278695
7.  Transmetatarsal Amputation: A Case Series and Review of the Literature 
Journal of Aging Research  2012;2012:797218.
Foot ulceration is a major cause of morbidity amongst patients with diabetes. In severe cases of ulceration, osteomyelitis and amputation can ensue. A distinct lack of agreement exists on the most appropriate level of amputation in cases of severe foot ulceration/infection to provide predictable healing rates. This paper provides an overview of the transmetatarsal amputation (TMA) as a limb salvage procedure and is written with the perspective and experiences of the Department of Podiatric Surgery at West Middlesex University Hospital (WMUH). We have reflected on the cases of 11 patients (12 feet) and have found the TMA to be an effective procedure in the management of cases of severe forefoot ulceration and infection.
doi:10.1155/2012/797218
PMCID: PMC3397208  PMID: 22811912
8.  Vascular Surgery, Microsurgery and Supramicrosurgery for Treatment of Chronic Diabetic Foot Ulcers to Prevent Amputations 
PLoS ONE  2013;8(9):e74704.
Introduction
Diabetic foot ulcers occur in approximately 2,5% of patients suffering from diabetes and may lead to major infections and amputation. Such ulcers are responsible for a prolonged period of hospitalization and co- morbidities caused by infected diabetic foot ulcers. Small, superficial ulcers can be treated by special conservative means. However, exposed bones or tendons require surgical intervention in order to prevent osteomyelitis. In many cases reconstructive surgery is necessary, sometimes in combination with revascularization of the foot.
There are studies on non surgical treatment of the diabetic foot ulcer. Most of them include patients, classified Wagner 1-2 without infection. Patients presenting Wagner 3D and 4D however are at a higher risk of amputation. The evolution of microsurgery has extended the possibilities of limb salvage. Perforator based flaps can minimize the donorsite morbidity.
Patients and Methods
41 patients were treated with free tissue transfer for diabetic foot syndrome and chronic defects. 44 microvascular flaps were needed. The average age of patients was 64.3 years. 18 patients needed revascularization. 3 patients needed 2 microvascular flaps. In 6 cases supramicrosurgical technique was used.
Results
There were 2 flap losses leading to amputation. 4 other patients required amputation within 6 months postoperatively due to severe infection or bypass failure. Another 4 patients died within one year after reconstruction. The remaining patients were ambulated.
Discussion
Large defects of the foot can be treated by free microvascular myocutaneous or fasciocutaneous tissue transfer. If however, small defects, exposing bones or tendons, are not eligible for local flaps, small free microvascular flaps can be applied. These flaps cause a very low donor site morbidity. Arterialized venous flaps are another option for defect closure.
Amputation means reduction of quality of life and can lead to an increased mortality postoperatively.
doi:10.1371/journal.pone.0074704
PMCID: PMC3772888  PMID: 24058622
9.  Pattern of limb amputation in a Kenyan rural hospital 
International Orthopaedics  2009;33(5):1449-1453.
Causes of limb amputations vary between and within countries. In Kenya, reports on prevalence of diabetic vascular amputations are conflicting. Kikuyu Hospital has a high incidence of diabetic foot complications whose relationship with amputation is unknown. This study aimed to describe causes of limb amputations in Kikuyu Hospital, Kenya. Records of all patients who underwent limb amputation between October 1998 and September 2008 were examined for cause, age and gender. Data were analysed using the statistical package for Social Sciences (SPSS) for Windows Version 11.50. One hundred and forty patients underwent amputation. Diabetic vasculopathy accounted for 11.4% of the amputations and 69.6% of the dysvascular cases. More prevalent causes were trauma (35.7%), congenital defects (20%), infection (14.3%) and tumours (12.8%). Diabetic vasculopathy, congenital defects and infection are major causes of amputation. Control of blood sugar, foot care education, vigilant infection control and audit of congenital defects are recommended.
doi:10.1007/s00264-009-0810-5
PMCID: PMC2899126  PMID: 19475408
10.  Salvage versus amputation: Utility of mangled extremity severity score in severely injured lower limbs 
Indian Journal of Orthopaedics  2007;41(3):183-187.
Background:
The purpose of the present study was to evaluate the clinical utility of Mangled extremity severity score (MESS) in severely injured lower limbs.
Materials and Methods:
Retrospectively 25 and prospectively 36 lower limbs in 58 patients with high-energy injuries were evaluated with the use of MESS, to assist in the decision-making process for the care of patients with such injuries. Difference between the mean MESS scores for amputated and salvaged limbs was analyzed.
Results:
In the retrospective study 4.65 (4.65 ± 1.32) was the mean score for the salvaged limbs and 8.80 (8.8 ± 1.4) for the amputated limbs. In the prospective study 4.53 (4.53 ± 2.44) was the mean score for the salvaged limbs and 8.83 (8.83 ± 2.34) for the amputated limbs. There was a significant difference in the mean scores for salvaged and amputated limbs. Retrospective 21 (84%) and prospective 29 (80.5%) limbs remained in the salvage pathway six months after the injury.
Conclusion:
MESS could predict amputation of severely injured lower limbs, having score of equal or more than 7 with 91% sensitivity and 98% specificity. There was a significant difference in the mean MESS scores in the prospective study (n=36), 4.53 (4.53 ± 2.44) in thirty salvaged limbs (83.33%) and 8.83 (8.83 ± 2.34) in six amputated limbs (16.66%) with a P-value 0.002 (P-value < 0.01). Similarly there was a significant difference in the mean MESS score in the retrospective study (n=25), 4.65 (4.65 ± 1.32) in twenty salvaged limbs (80%) and 8.80 (8.8 ± 1.4) in five amputated limbs (20%) with a P-value 0.00005 (P-value < 0.01). MESS is a simple and relatively easy and readily available scoring system which can help the surgeon to decide the fate of the lower extremity with a high-energy injury.
doi:10.4103/0019-5413.33679
PMCID: PMC2989115  PMID: 21139741
Mangled lower extremity; Mangled extremity severity score; salvage versus amputation
11.  Soft Tissue Sarcomas of the Hand: Functional Reconstruction and Outcome Analysis 
Hand (New York, N.Y.)  2008;3(3):229-236.
Functional hand reconstruction following treatment of soft tissue sarcomas (STS) is a difficult surgical problem. Because survival rates between amputation and limb salvage do not differ, there is a trend toward reconstruction. Unlike amputation, hand salvage usually requires multiple complex operations in combination with adjuvant radiation or chemotherapy, prolonged rehabilitation, and carries a high complication rate. We investigated tumor recurrence, survival, and scored functional outcomes to determine if limb salvage is justified after hand STS resection. Patients treated for hand STS between years 1985 and 2005 were reviewed by two surgeons in three medical centers. All patients having functional reconstruction instead of amputation were reviewed. Patient demographics, tumor type and grade, resection extent, reconstruction procedure, timing, adjuvant therapy use, complications, tumor recurrence, survival, and functional outcome were recorded and analyzed. Five patients underwent functional reconstruction for hand STS. All patients underwent attempted curative resections, and four patients received neoadjuvant or postoperative radiation therapy. Three patients received adjuvant chemotherapy. Reconstructive techniques included three modified pollicizations, one free-tissue transfer, and one groin flap. All patients were alive and disease-free at a mean follow-up of 5 years (range 1.5–17 years). Three patients (60%) had local complications, requiring secondary surgeries. Two complications were related to radiation therapy. Hand function was evaluated using the Enneking Scoring System, and ranged from 17 to 28. The average Enneking score was 22.4, representing an average preservation of 74.6% of function. Because most patients retain excellent function and survival is unaffected, we advocate functional reconstruction despite high complication rates.
doi:10.1007/s11552-008-9089-z
PMCID: PMC2525882  PMID: 18780101
Limb salvage; Hand surgery; Enneking score
12.  Surgical revascularization techniques for diabetic foot 
Diabetes is an important risk factor for atherosclerosis. The diabetic foot is characterized by the presence of arteriopathy and neuropathy. The vascular damage includes non-occlusive microangiopathy and macroangiopathy. Diabetic foot wounds are responsible for 5–10% of the cases of major or minor amputations. In fact, the risk of amputation of the lower limbs is 15–20% higher in diabetic populations than in the general population. The University of Texas classification is the reference classification for diabetic wounds. It distinguishes non-ischemic wounds from ischemic wounds which are associated with a higher rate of amputation. The first principles of treatment are the control of pain of an eventual infection. When ischemia is diagnosed, restoration of pulsatile blood flow by revascularization may be considered for salvaging the limb. The treatment options are angioplasty with or without stenting and surgical bypass or hybrid procedures combining the two. Distal reconstructions with anastomosis to the leg or pedal arteries have satisfactory limb-salvage rates. Subintimal angioplasty is a more recent endovascular technique. It could be suggested for elderly patients who are believed to be unsuitable candidates for a conventional bypass or angioplasty. The current article would focus on the various revascularization procedures.
doi:10.1016/j.jcdr.2012.10.002
PMCID: PMC3770111  PMID: 24027360
Angioplasty; Bypass; Diabetes; Revascularization
13.  Limb salvage surgery 
The threat of lower limb loss is seen commonly in severe crush injury, cancer ablation, diabetes, peripheral vascular disease and neuropathy. The primary goal of limb salvage is to restore and maintain stability and ambulation. Reconstructive strategies differ in each condition such as: Meticulous debridement and early coverage in trauma, replacing lost functional units in cancer ablation, improving vascularity in ischaemic leg and providing stable walking surface for trophic ulcer. The decision to salvage the critically injured limb is multifactorial and should be individualised along with laid down definitive indications. Early cover remains the standard of care, delayed wound coverage not necessarily affect the final outcome. Limb salvage is more cost-effective than amputations in a long run. Limb salvage is the choice of procedure over amputation in 95% of limb sarcoma without affecting the survival. Compound flaps with different tissue components, skeletal reconstruction; tendon transfer/reconstruction helps to restore function. Adjuvant radiation alters tissue characters and calls for modification in reconstructive plan. Neuropathic ulcers are wide and deep often complicated by osteomyelitis. Free flap reconstruction aids in faster healing and provides superior surface for offloading. Diabetic wounds are primarily due to neuropathy and leads to six-fold increase in ulcerations. Control of infections, aggressive debridement and vascular cover are the mainstay of management. Endovascular procedures are gaining importance and have reduced extent of surgery and increased amputation free survival period. Though the standard approach remains utilising best option in the reconstruction ladder, the recent trend shows running down the ladder of reconstruction with newer reliable local flaps and negative wound pressure therapy.
doi:10.4103/0970-0358.118603
PMCID: PMC3901908  PMID: 24501463
Limb salvage; limb trauma; lower limb reconstruction; foot ulcers
14.  Hyperspectral Imaging in Diabetic Foot Wound Care 
Diabetic foot ulceration is a major complication of diabetes and afflicts as many as 15 to 25% of type 1 and 2 diabetes patients during their lifetime. If untreated, diabetic foot ulcers may become infected and require total or partial amputation of the affected limb. Early identification of tissue at risk of ulcerating could enable proper preventive care, thereby reducing the incidence of foot ulceration. Furthermore, noninvasive assessment of tissue viability around already formed ulcers could inform the diabetes caregiver about the severity of the wound and help assess the need for amputation. This article reviews how hyperspectral imaging between 450 and 700 nm can be used to assess the risk of diabetic foot ulcer development and to predict the likelihood of healing noninvasively. Two methods are described to analyze the in vivo hyperspectral measurements. The first method is based on the modified Beer-Lambert law and produces a map of oxyhemoglobin and deoxyhemoglobin concentrations in the dermis of the foot. The second is based on a two-layer optical model of skin and can retrieve not only oxyhemoglobin and deoxyhemoglobin concentrations but also epidermal thickness and melanin concentration along with skin scattering properties. It can detect changes in the diabetic foot and help predict and understand ulceration mechanisms.
PMCID: PMC2956800  PMID: 20920429
diabetic foot ulcer; hyperspectral imaging; tissue oximetry; wound care
15.  The utility of scores in the decision to salvage or amputation in severely injured limbs 
Indian Journal of Orthopaedics  2008;42(4):368-376.
The decision to amputate or salvage a severely injured limb can be very challenging to the trauma surgeon. A misjudgment will result in either an unnecessary amputation of a valuable limb or a secondary amputation after failed salvage. Numerous scores have been proposed to provide guidelines to the treating surgeon, the notable of which are Mangled extremity severity score (MESS); the predictive salvage index (PSI); the Limb Salvage Index (LSI); the Nerve Injury, Ischemia, Soft tissue injury, Skeletal injury, Shock and Age of patient (NISSSA) score; and the Hannover fracture scale-97 (HFS-97). These scores have all been designed to evaluate limbs with combined orthopaedic and vascular injuries and have a poor sensitivity and specificity in evaluating IIIB injuries. Recently the Ganga Hospital Score (GHS) has been proposed which is specifically designed to evaluate a IIIB injury. Another notable feature of GHS is that it offers guidelines in the choice of the appropriate reconstruction protocol. The basis of the commonly used scores with their utility have been discussed in this paper.
doi:10.4103/0019-5413.43371
PMCID: PMC2740356  PMID: 19753223
Open fractures; severely injured limbs; limb injury severity score
16.  Angiography Underestimates Peripheral Atherosclerosis: Lumenography Revisited 
Journal of Endovascular Therapy  2008;15(1):117-125.
Abstract
Purpose: To compare angiograms, considered the gold standard for diagnostic imaging of peripheral arterial disease (PAD), to the corresponding histological sections of popliteal and tibial vessels obtained after amputation to determine if angiography fails to define atheroma burden in “normal appearing” arteries in patients with PAD.
Methods: Between 2004 and 2006, 69 patients underwent amputation of a lower extremity for severe tissue loss, gangrene, or pedal sepsis precluding limb salvage. Popliteal and tibial vessels were harvested, perfusion-fixed, and analyzed histologically. Thirty-four of these patients had pre-amputation angiography during attempted salvage procedures. Angiograms with patent or minimally diseased vessel segments (n = 19) were assessed for stenoses, diameter, and calcification by 3 vascular surgeons (n = 72 evaluations). These results were compared to corresponding cross-sectional histological slides (n = 66) in a blinded manner.
Results: Angiograms performed prior to above-knee (n = 9) or below-knee (n = 10) amputation revealed 24 stenoses with a mean (±SD) diameter-reducing stenosis of 19.5%±15.2%. Corresponding histological cross sections revealed greater linear stenoses measured via boundaries of the internal elastic lamina (IEL stenosis, 28.9%±20.2%, p = 0.003 versus angiography) or via boundaries of the external elastic membrane (vessel stenosis, 43.1%±15.2%, p<0.0001). Stenosis calculated by area methods (IEL area) were greater and measured 39.2%±24.2% (p<0.0001) and 60.9%±15.2% (vessel area, p<0.0001). Popliteal arteries had greater discrepancy in stenosis measurement than tibial arteries (18.5%±14.6% versus 34.9%±21.0%, p = 0.0005). However, evaluations of tibial arteries for concentricity of plaque (44% versus 69%, p = 0.08) and calcification grade (1.6 versus 2.2, p = 0.002) by angiography were discordant with histological analyses. Measurement of arterial diameter by histology for popliteal arteries (6.2±0.9 mm) and tibial arteries (3.1±0.7 mm) was greater than angiographic diameter determination (p<0.001).
Conclusion: Angiography provides information on luminal characteristics of peripheral arteries but severely underestimates the extent of atherosclerosis in patients with PAD even in “normal appearing” vessels.
doi:10.1583/07-2249R.1
PMCID: PMC2795386  PMID: 18254670
peripheral artery disease; stenosis; atheroma; popliteal artery; tibial artery; histology; angiography
17.  Racial Disparities in the Use of Revascularization Before Leg Amputation in Medicare Patients 
Objective
Black patients with peripheral arterial disease undergo amputation at two to four times the rate of white patients. In order to determine whether differences in attempts at limb salvage might contribute to this disparity, we studied the limb care received prior to amputation by black patients compared to whites.
Methods
Using inpatient Medicare data for years 2003-2006, we identified a retrospective sample of all beneficiaries who underwent major lower extremity amputation. ‘Limb salvage care’ was defined as limb-related admissions and procedures that occurred during the two years prior to amputation. We used multiple logistic regression to compare rates of revascularization and other limb care received by black versus white amputees, adjusting for individual patient characteristics. We then controlled for hospital referral region in order to assess whether differences in care might be attributable to the geographic regions in which black and white patients received care. Finally, we examined the timing of revascularization relative to amputation for both races.
Results
Our sample included 24,600 black and 65,881 white amputees. Compared with whites, black amputees were more likely to be female and had lower socioeconomic status. Average age, rates of diabetes, and levels of comorbidity were similar between races. Black amputees were significantly less likely than whites to have undergone revascularization (23.6 vs. 31.6%, p<0.0001), any limb-related admission (39.6 vs. 44.7%, p<0.0001), toe amputation (12.9 vs. 13.8%, p<0.0005) or wound debridement (11.6 vs. 14.2%, p<0.0001) prior to amputation. After adjusting for differences in individual patient characteristics, black amputees remained significantly less likely than whites to undergo revascularization (OR 0.72 [95% confidence interval 0.68-0.76]), limb-related admission (OR 0.81 [0.78-0.84]), or wound debridement prior to amputation (OR 0.80 [0.75-0.85]). Timing of revascularization relative to amputation was similar between races. Observed differences in care were shown to exist within hospital referral regions, and were not accounted for by regional differences in where black and white patients received care.
Conclusion
Black patients are much less likely than whites to undergo attempts at limb salvage prior to amputation. Further studies should explore whether this disparity might be attributable to race-related differences in severity of arterial disease, patient preferences, or physician decision-making.
doi:10.1016/j.jvs.2011.02.035
PMCID: PMC3152619  PMID: 21571495
18.  Biomechanics of the Diabetic Foot: Consideration in Limb Salvage 
Advances in Wound Care  2013;2(3):107-111.
Significance
The biomechanics of the diabetic foot is altered and maladaptive. We lack a thorough understanding of the functional consequences of limb salvage. We currently rely on observation and descriptive data pertaining to the biomechanics of the diabetic foot.
Recent Advances
Technology has driven our ability to objectively describe biomechanics of the diabetic foot. Dynamic, segmental, gait analysis in conjunction with peak plantar pressure measurements have provided valuable insight.
Critical Issues
The biomechanical pathogenesis of a chronic ulceration that necessitates limb salvage is difficult to capture. The subsequent changes that occur after limb salvage are even more difficult to understand. However, methodical biomechanical analysis over the past several decades have provided a deeper understanding of diabetic foot function.
Future Directions
Ultimately, a better understanding of the biomechanics of the diabetic foot would allow us to better select the most appropriate amputation level and maximize function after limb salvage attempt.
doi:10.1089/wound.2011.0315
PMCID: PMC3840549  PMID: 24527334
19.  Limb Salvage Surgery and Wound Treatment in the Establishment of Globally Standardized Diabetes, Amputation, and Limb Salvage Centers to Address Lower Extremity Morbidity and Mortality in Thailand 
Diabetes and its consequences, particularly diabetic foot ulcerations and amputations, are increasing exponentially on a global level. Universal interest exists in the establishment of educational programs, clinics, and patient materials. However, the availability and skills needed to develop, implement, and consistently manage diabetes and related problems are lacking. This article reviews problems related to care of the diabetic foot, with a focus on Thailand as a model. Recommendations are made to assist with the development and implementation of limb salvage centers for the treatment of the at-risk diabetic foot. The guidelines presented may be applied to any countries where diabetic foot care is in the initial stages of development.
doi:10.1016/j.jcws.2010.09.002
PMCID: PMC3601850  PMID: 24527142
Diabetes; Foot; Globalization; Limb salvage; Thailand; Wound treatment
20.  Partial amputations of the foot for diabetic gangrene. 
Over a 5-year period 68 diabetic patients underwent 102 primary partial amputations of the foot for infected diabetic gangrene. Seventy (69%) of these operations healed without further local surgery, but five patients needed seven femoropopliteal bypass grafts (two bilateral) to achieve healing. In total, 32 primary operations needed revision by further surgery to the foot or by leg amputation. Of the original operations 31% were carried out by a consultant surgeon; the rest (69%) were performed by a junior surgeon. By contrast, only four of the 32 operations needing revision (12%) had originally been done by a consultant, whereas 28/32 (88%) had been carried out by a junior surgeon. Of limbs at risk 65/80 (81%) were salvaged. Five patients died during their hospital admission, giving an overall mortality of 7%.
PMCID: PMC2498849  PMID: 3190133
21.  The Diabetic Rapid Response Acute Foot Team: 7 Essential Skills for Targeted Limb Salvage 
Eplasty  2009;9:e15.
Objective: People with diabetes are prone to develop lower-extremity ulcerations and infections, both of which serve as major risk factors for limb amputation. The development of lower-extremity complications of diabetes is associated with increased morbidity and mortality. Recently, there has been increasing interest in the development of interdisciplinary teams to manage the myriad factors that complicate the treatment of high-risk patients, particularly in the perihospitalization period. Methods: This article presents 7 essential skills that necessarily allow the limb salvage team to appropriately manage the most common presenting comorbidities in patients with diabetes, including vasculopathy, infection, and deformity. Results: Seven essentials skills have been demonstrated to promote the greatest salvage outcomes, and these are the ability to (1) perform hemodynamic and anatomic vascular assessment with revascularization, as necessary; (2) perform neurologic workup; (3) perform site-appropriate culture technique; (4) perform wound assessment and staging/grading of infection and ischemia; (5) perform site-specific bedside and intraoperative incision and debridement; (6) initiate and modify culture-specific and patient-appropriate antibiotic therapy; and (7) perform appropriate postoperative monitoring to reduce risk of reulceration and infection. Conclusions: Utilization of these 7 essential skills as the core basis for interdisciplinary limb salvage team models will provide clinicians guidance when establishing such teams. Interdisciplinary teams have been demonstrated to improve quality and efficiency of patient care, thus improving overall outcomes and reducing amputation rates.
PMCID: PMC2680239  PMID: 19436764
22.  Results of Infrapopliteal Endovascular Procedures Performed in Diabetic Patients with Critical Limb Ischemia and Tissue Loss from the Perspective of an Angiosome-Oriented Revascularization Strategy 
Our aim was to describe our experience with infrapopliteal endovascular procedures performed in diabetic patients with ischemic ulcers and critical ischemia (CLI). A retrospective study of 101 procedures was performed. Our cohort was divided into groups according to the number of tibial vessels attempted and the number of patent tibial vessels achieved to the foot. An angiosome anatomical classification of ulcers were used to describe the local perfusion obtained after revascularization. Ischemic ulcer healing and limb salvage rates were measured. Ischemic ulcer healing at 12 months and limb salvage at 24 months was similar between a single revascularization and multiple revascularization attempts. The group in whom none patent tibial vessel to the foot was obtained presented lower healing and limb salvage rates. No differences were observed between obtaining a single patent tibial vessel versus more than one tibial vessel. Indirect revascularization of the ulcer through arterial-arterial connections provided similar results than those obtained after direct revascularization via its specific angiosome tibial artery. Our results suggest that, in CLI diabetic patients with ischemic ulcers that undergo infrapopliteal endovascular procedures, better results are expected if at least one patent vessel is obtained and flow is restored to the local ischemic area of the foot.
doi:10.1155/2014/270539
PMCID: PMC3914461  PMID: 24527215
23.  Prediction of Limb Salvage after Therapeutic Angiogenesis by Autologous Bone Marrow Cell Implantation in Patients with Critical Limb Ischemia 
Annals of Vascular Diseases  2011;4(1):24-31.
Purpose: Despite advances in therapeutic angiogenesis by bone marrow cell implantation (BMCI), limb amputation remains a major unfavorable outcome in patients with critical limb ischemia (CLI). We sought to identify predictor(s) of limb salvage in CLI patients who received BMCI.
Materials and Methods: Nineteen patients with CLI who treated by BMCI were divided into two groups; four patients with above-the-ankle amputation by 12 weeks after BMCI (amputation group) and the remaining 15 patients without (salvage group). We performed several blood-flow examinations before BMCI. Ankle-brachial index (ABI) was measured with the standard method. Transcutaneous oxygen tension (TcPO2) was measured at the dorsum of the foot, in the absence (baseline) and presence (maximum TcPO2) of oxygen inhalation. 99mtechnetium-tetrofosmin (99mTc-TF) perfusion index was determined at the foot and lower leg as the ratio of brain.
Results: Maximum TcPO2 (p = 0.031) and 99mTc-TF perfusion index in the foot (p = 0.0068) was significantly higher in the salvage group than in the amputation group. Receiver operating characteristic (ROC) curve analysis identified maximum TcPO2 and 99mTc-TF perfusion index in the foot as having high predictive accuracy for limb salvage.
Conclusion: Maximum TcPO2 and 99mTc-TF perfusion index in the foot are promising predictors of limb salvage after BMCI in CLI.
doi:10.3400/avd.oa.10.01049
PMCID: PMC3595769  PMID: 23555423
critical limb ischemia; bone marrow cell implantation; limb salvage; 99mtechnetium-tetrofosmin perfusion scintigraphy; transcutaneous oxygen tension
24.  Clinical and behavioral factors associated with management outcome in hospitalized patients with diabetic foot ulcer 
Objectives
Diabetic foot ulcer (DFU) has been linked to high mortality and morbidity in diabetic patients. In spite of the increasing prevalence of diabetes and its complications, this issue has not been adequately studied in Iran.
Materials and methods
In this cross-sectional study we attempt to describe the prevalence of diabetic foot amputation in patients admitted to our training hospitals in Urmia, Iran, and also to determine the associated demographic, behavioral, and clinical factors.
Results
Of 94 patients with DFU, 34 (32%) had amputation. Those with amputation were significantly older and were also less educated than those without amputation, had longer duration of diabetes (hence were more likely to suffer from complications), and had high-risk wounds plus a poor glycemic control. On logistic regression analysis two variables were associated with amputation: Wagner classification ≥3 and HbA1c. On a receiver operating characteristics curve, the HbA1c cutoff point of 9.7% significantly discriminated to predict increasing risk of amputation.
Conclusion
Both glycemic control and promoting the knowledge of patients and health care professionals in order to diagnose DFU in the early stages and to prevent development of the high-grade wounds would be a significant step in reducing the burden of DFU and its effect on quality of life in Iran.
doi:10.2147/DMSO.S25309
PMCID: PMC3224658  PMID: 22135500
diabetes mellitus; foot ulcer; amputation
25.  Proximal Tibial Metaphyseal Fractures with Severe Soft Tissue Injury: Clinical and Functional Results at 2 Years 
Background
Controversy exists regarding management of proximal tibial metaphyseal fractures with severe soft tissue injury. It is unclear whether limb salvage or early amputation results in the best functional and clinical outcomes.
Questions/Purpose
We hypothesized that in this group of patients, there is no difference in functional outcomes, complication rates, clinical outcomes, or objective physical function related to the treatment approach.
Methods
We used the LEAP study database to perform a retrospective comparative review of a subset of patients with proximal tibial metaphyseal fractures (AO/OTA 41A, B, and C) with associated severe soft tissue injuries comparing the outcomes of patients who were treated with either limb salvage or amputation.
Results
Although there were major differences in clinical and functional outcomes based on patients’ sociodemographics at 2 years, no differences in clinical or functional outcomes were detected regardless of whether amputation or limb salvage was performed. Severity of soft tissue injury was more predictive of outcome than the surgical approach used.
Conclusions
Sociodemographics and soft tissue injury severity are more important than treatment approach for predicting clinical and functional outcomes at 2 years in patients with proximal tibia metaphyseal fractures with severe soft tissue injury.
Level of Evidence
Level III, retrospective comparative study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-009-1148-4
PMCID: PMC2865598  PMID: 19862585

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